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SAN JOAQUIN COUNTY -INVIRONMENTAL HEALTH DEPARTMEN•. o00 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: 7/l Page / Of M Facility Address: City: C-0 /9 G}� Inspec 'on Date: FA #:PR C?�� #: 05AaAf l Program Element: f. g 3 7--� 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#: 2� 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: MLT p /2- �J Total Capacity: Z V0 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) IVContainers (2821) #of Containers: TA#: O51 %o2,30 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ["Containers (282 1) #of Containers: TA#: 967/ 7oZ3' 3 J� (>250 gallons) (>55 gallons and <250 gallons) Type: Product T Total Capacity: gallons (per tank or cumulative for.containers by product type) Install Date: ❑ Tank (2820) I�ontainers (2821) #of Containers: �' TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: 11 AO gallons (per tan or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: a ,33 5 (>250 gallons) (>55 gallons and <250 gallons) �- Product Type: Total Capacity: 2 fl gallons Install Date: (per tank or cumulativ for containers by product type) Total Capacity this Page:/ Z 6 gallons FTotal Capacity for Site: gallons Com. EHD Inspector: ! , Reviewed Date: / By Initial: 1 _ �• 0 t1 Entered Date: By Initial: EHD 28-01 01/16/08