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SAN JOAQUIN COUNTY N041 ENVIRONMENTAL HEALTH DEPAR�N 600 East Main Street, Stockton, CA 95202-s029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Tle v61z'/r✓1- Page / of Facility Address City: �-1(�57- r r { j Inspecti Da FA #: DD I PR #: D5� 8 I �l � ProggrmlElement: � alp l 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) ❑ Containers (2821) #of Containers: ,TA#: O 5 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: r%Q04 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 (>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#: 3 (>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#: 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: 94-02''?:) gallons Total Capacity for Site: O v gallons Comments: 2 © 3 EHD Inspector: Reviewed Date: By Initial: �,�y'�. D 6 ered Date: Initial `7 _p FB / EHD 28-01 01/16/08