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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN' 600 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:g l NCo �5 fi,AitvTr� APAR J� e of Facility Add r s� 9 HA Rt #3 L) k U City: P (,i4� Inspe io Date: � 2s l� � FA #: 000-3? 9? PR #: Program Element: Z 3/ 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. ank (2820) ❑ Containers (2821) #of Containers: TA#: LQA-41!� (>250 gallons) (>55 gallons and <250 gallons) T 1 Product Type: 9/ L Total Capacity: � o ,)gallons (per tank or cumulative or Containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: -t_- TA#: 5-1 4e 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: X/ yc2jf5�"4 C/ D/ Total Capacity: '//0 gallons Install Date: (per tank or cumulative for containers by product type) CiYTank (2820) ❑ Containers (2821) #of Containers: TAM 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: AA S g Total Capacity: To ° gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 4 Product Type: Total Capacity: �o p gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: Q gallons Total Capacity for Site: /s/0 gallons Comments: EHD Inspector: Y ,(� C r'✓" Reviewed Date: By Initial: VA J1 7el—A Entered Date: By Initial: l Ap EHD 28-01 01/16/08