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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME] 600 East Main Street, Stockton, CA 95202-30,, Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Cc� Page of Facility Address:City: Inspect' n 7 LT 1 E n/ cA IV Ig a I FA #: 1n337 1 PR #: 5-/J- Program Element: X13 -V Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum > 1320 gallons in tanks and containers over 55 gallons. Com ete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (2821) #of Containers: TA#: i J,5YP5&a 1 (>250 gallons) (>55 gallons and <250 gallons) // Product Type: f� � !r Total Capacity: ?13-6 gallons Install Date: (per tank or cumulative for containers by product type) Q�ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: o d gallons (per tank or cumulative for containers by product type) Install Date: ©/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 It 3 (>250 gallons) (>55 gallons and <250 gallons) 3 � Product Type: Total Capacity: l o O gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: Or TA#: �2 6-16, 6:36- 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: L b IV 0 0 gallons Install Date: (per tank or cumulative for containers by product type) E?"'Tank (2820) ❑ Containers (2821) #of Containers: TA#: D I j.1r3& 5 (>250 gallons) (>55 gallons and <250 gallons) / Product Type: �i/A fwd 01'L Total Capacity: / 6 U "gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: > Jr d gallons Total Capacity for Site: gallons Comments: EHD Inspector: ReviewedDate: By Initial: VI(TI l0 10. Entered Date: By Initial: zz �// EHD 28-01 01/16/08