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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMET 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page � of % Facility Address: City: Ins pe ti Dat Dy 5 Sfik. , FA #: O 0 © � 1 � PR #: � �� Program Element: 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#: (>250 gallons) (>55 gallons and <250 gallons) 1 Product -Type: e: yp� Total Capacity: I" v DO gallons (per tank or cumulative for containers by product type) Install Date: U Tank (2820) ❑ Containers (2821) #of Containers: ' TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: Z2-170 gallons (per tank or cumulative for containers by product type) Install Date: VTank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 35,C)0 Product Type:(" ' Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: t%1 to gZ 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: �/%1 j`' P Total Capacity: 5 D 0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: /" 2 ( ;� gallons Total Capacity for Site: Z ('7 r� gallons Comments: ; EHD Inspector:�// Reviewed II Date: By Initial: \JA Entered Date: By Initial: 1 ,,6/ W B EHD 28-01 01/16/08