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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 600 East Main Street, Stockton, CA'95202-3029 Telephone: (209) 468-3420 Far: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility NT Page of N C, y C6 AITP�t9- _� Facility Address: �' �i City: �!e%1G Inspecti n Dat -/z-77O b N `U► FA #: 500 �o PR #: is?94 Program Element: Z83' Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >:1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. ank (2820) ❑ Containers (2821) #of Containers: TA#:OI�Q 86- 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: �f/, ,S Total Capacity: %a o o gallons (per tank or cumulative for containers by product type) Install Date: P"fank (2820) ❑ Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: -/ ' o gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: Z a 4 gallons Fotal Capacity for Site: 0 6 G gallons Comments: g6o � S 0 cy EHD Inspector: Reviewed e: By Initial: Entered Date: By Initial: a EHD 28-01 01/16/08