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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENI 000 East Main Street, Stockton, CA 95202-302y Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: _ DS(A-) Q— Page of Facility Address: \ �Sglo N O0 -0S City: Inspectio Date: l TQC u'i � FA #: IT PR #: Program men 3 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: o' -'es -e-0 Total Capacity: 10/OD O gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: 2 >250 gallons) (>55 gallons and <250 gallons) Product Type: 6-a5 p (�� e Total Capacity: S gallons (per tank or cumulative for containers by product type) Install Date: [ Tank (2820) ElContainers (2821) #of Containers: TA#: 3 G (>250 gallons) (>55 gallons and <250 gallons) Total Capacity: eff nr es Product Type: �f ci gallons Install Date. (per tank or cumulative for containers by product type) 0 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: O 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: Q Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: I �.1 EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: EHD 28-01 01/16/08