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SAN JOAQUIN COUNTY "ENVIRONMENTAL HEALTH DEPARTMENT ,JO 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: �� T14G-S Page of g Facility Address: City: Inspectioy3 ake: �f � FA #: -L'34 PR #: Program Elem nt: z g 3l 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#: 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: /oo© gallons —� Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0671-7 3 $ 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: j e oz)gallons (per tank or cumulative for containers by product type) Install Date: [� Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: TO 2 O / Total Capacity: / Zz9 gallons Install Date: (per tank or cumulative for containers by product type) P -"f nk (2820) ❑ Containers (2821) #of Containers: TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: � y� G1 L/ Total Capacity: / Z D gallons Install Date: (per tank or cumulative for containers by product type) ©'Tank (2820) ❑Containers (2821) #of Containers: TA#: 6�5) 7.,'j$l0 5 (>250 gallons) (>55 gallons and <250 gallons) -O Product Type: /it//9S ?� Total Capacity: / -. gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: Zs q gallons Total Capacity for Site: 3 d gallons Comments: EHD Inspector: �. Reviewed By Initial: Date:Entered 41 kd k -D Date: By Initial: I6 l EHD 28-01 01/16/08