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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENI 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 EHD 28-01 01/16/08 Fa Hi Name: ` r Page of N ��a� V tw 1�l Facility Address: Ci Inspection Date: `- til ova cA 95221j —7—;- 09 FA #: PR #: 1 N y 36 f'f 3 Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) N Containers (282 1) #of Containers: 3 TA#: 351522 (>250 gallons) (>55 gallons and <250 gallons) j� ++ 1 , Product Type: c I Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (282 1) #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: �� gallons Total Capacity for Site: -11 7(iU gallons Comments: EHD Inspect o / l Reviewed Date: Entered Date: By Initial: By Initial: EHD 28-01 01/16/08