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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN`, 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: w Qb �� (1L, — C A Page __I—__ of Facility Address: ("U W. WASC,0 �/l City: S� . S�&(lc� e: Inspect716 /27 FA #: O � U PR #: P-5-97-717 Progra6 Element: 2 3 1 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. X, Tank (2820) ❑ Containers (2821) #of Containers: TA#:)_S_�Fj' 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: i L, - 2 -- Total Total Capacity: gallons (per tank or cumulative fo omainers by product type) Install Date: ❑ Tank (2820) iners (2821) n alners: TA#: (>250 gallons) (>55 gallons and < 2 Product Type: Total Capacity: gallons (per tank or cumulative containers by product type) ^ sta ate: ❑ Tank (2820) ❑ Containers (2821) #of Conta' rs: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) ^ Product Type: C u A-2 .9p 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: 6 gallons Total Capacity for Site: UV 6 gallons Comments: o2din �< EH D Inspector: Reviewed Date: By Initial: Entered By Initial: Date: EHD 28-01 01/16/08