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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM EHD 28-01 01/16/08 Facility Name: K of iv:t�V�yAJPage i�t��ui� Facility Address: 2 City: I Az;� /AQSZZo Inspection Date: 7- S -07 FA #: IOU PR #: 530 ��3 Program Element: 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. jgl Tank (2820) ❑ Containers (282 1) #of Containers: TA#: 1 (>250 gallons) (>55 gallons and <250 gallons) '' n Product Type: �i�.Y Total Capacity: gallons "Install (per tank or cumulative for containers by product type) Date: �J Tank (2820) ❑ Containers (2821) #of Containers: TA#: QLS1 $ S� d 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: �M gallons (per tank or cumulative for containers by product type) Install Date: tg Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: � � eve Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: 55 Tank (2820) ❑ Containers (2821) #of Containers: TA#:, g 4 (>250 gallons) (>55 gallons and <250 gallons) 7eA Product Type: Total Capacity: -AMU gallons Install Date: (per tank or cumulative for containers by product type) R, Tank (2820) ❑ Containers (2821) #of Containers: TA#: Q� g S33 5 (>250 gallons) (>55 gallons and <250 gallons) aa Total Capacity: a Product Type: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: �� Reviewed ( Date: By Initial: � Entered Date: _ By Initial: y � � /� EHD 28-01 01/16/08