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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 - # f �// /V N / Page of Facility Address: 5- 7n �, r L �j V R'i"A/ d (CA/ L 1,;::f -6R Inspect' ? 71, 7 !� {4 FA #: d0p3� PR #: 1 Program Element: 7--q 00 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. ❑ Tank (2820) ❑ Containers21) #of Containers: TA#: (>250 gallons) (>55 gallons and <2 gallons) 1 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by/ -duct type) ❑ Tank (2820) ❑ iners (2821) #of Containers: TA#: (>250 gallons) (>55 and <250 gallons) /gans 2 Product Type: Total Capacity:— gallons Install Date: (per tank or cumulative for co finers by product type) ❑ Tank (2820) Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumula a for containers by product type) ❑ Tank (2 20) El Containers (2821) #of Containers: TA#: (1250 gallons (>55 gallons and <250 gallons) 4 Product Type: Total Caacity: gallons Install Date: (per tank or umulative for containers by product type) ❑ Ta (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 Ilons) (>55 gallons and <250 gallons) Product Type: Tota Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: IV -0 —,r Ay /j�• IjjjN/✓ EHD Inspector: Reviewed By Initial: Date: ,I vv'_ /1, �1 Entered By Initial: Date: V Doil EHD 28-01 01/16/08