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SAN JOAQUIN COUNTY :NVIRONMENTAL HEALTH DEPARTMENT 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: T��— Page � of Facility Address: q i5�►� ►�, 1 City: �z � 90yz Inspection Date: 2-1r-1/ #: quo PR #: o2�1'FA Progra n f y ,em� 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 type. ontainers (2821) ❑ Tank (2820) r>55 #of Containers: TAM 0 5"aD 1 D � 1 (1250 gallons) allons and <250 gallons) Product T e• 7nl Type:�Q��1�� Total Capacity: gallons ci'V�t� Install Date: (per tank or cumulative for containers y product type) ❑ Tank (2820) rContainers (282 1) #of Containers: ��-- TA#: &6��2Q 10 00, 2 (>250 gallons) (>55 gallons and <250 gallons) Total Capacity: gallons Product Type: Gt (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) V Containers (2821) #of Containers: 2 TA#: b5 �j 3 (1250 gallons) (>55 gallons and <250 gallons) Product Type: `M✓ '.3.1 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 (>250 gallons) (>55 gallons and X250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ 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: gallons Total Capacity for Site: V1910Agallons Comments: EHD Inspector: �q In(� �� Reviewed Date- By Initial: (ZU�' if . I Entered Date: By Initial �� EHD 28-01 01/16/08