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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN" 600 East Main Street, Stockton, CA 95202--iu29 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name�e A A 1 / D 'v (/-" Pae of g Facility Address: Ci Z W. /�( FN I � n Date Ins 77Vf'F FA #: D O / b PR S., z 6 9 S.3 Program EI ent: Ob Ir 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. [;k"'fank (2820) ❑ Containers (2821) #of Containers: TA#:,� 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: G /95 Total Capacity: �/ o 4-0 gallons Install Date: (per tankor cumulative for containers by product type) 1? lank (2820) ❑ Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) / Product Type: 6 rys Total Capacity: .S C o gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: 1 T : %Fi'1 3 (>250 gallons) (>55 gallons and <250 gallons) �^� Product Type: Total Capacity: D O O 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 <250 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: !tG S- gallons FTotal Capacity for Site: ? gallons Comments: EHD Inspector: Reviewed Date:Entered By Initial: �.'f By Initial: / Dater EHD 28-01 01/16/08