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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEP A0 East Main Street, Stockton, CA 95202 -30 - 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: d-. City: Inspe ti Dat D n d 5 S 1 FA #: O � � � � e PR #: � D Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product e. �/ L� Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 (>250 gallons) (>55 gallons and <250 gallons) Product -T e• / yp � Total Capacity: [ d v 0 0 gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: ' TA#: r9t Zc5-? 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: P� z 2 Total Capacity: 7.,-2-00 gallons (per tank or cumulative for containers by product type) Install Date: VTank (2820) ❑ Containers (2821) #of Containers: TA#: g,� le6-3-3 3 (>250 gallons) (>55 gallons <250 gallons) Product Type: � Total Capacity: gallons Install Date: (per tank or cumulative r containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0s -z tem g`Z 4 (>250 gallons) (>55 gallons and <250 gallons) r Product Type: �/f� -may' op v Total Capacity: U gallons Install Date: (per tank or cumulative or containers by product type) O Tank (2820) ❑ Containers (2821) #of Containers: TA#: �2Js'17 D`Dom 5 (>250 gallons) (>55 gallons and <250 gallons) �Product Type: �iY Gi Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: G5� gallons Total Capacity. for Site: c gallons 1 Comments: „✓ 1>'- —'` y ,c Iti }} l l EHD Inspector: , Reviewed By Initial: Date: c� 6; l%1 u Entered Date: By Initial: j B EHD 28-01 01/16/08 I—