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SAN JOAQUIN COUNTY E0( NVIRONMENTAL HEALTH DEPARTMI East Main Street,Stockton,CA 95202-3vz, Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: ` S �i C S 'T r/' S Page of Facility Address: City: Inspectio Da e: 25��3 a- wy 9 9 �' � �log FA#: PR#: ProgramElement: 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. OR'Tank (2820) ❑ Containers (2821) #of Containers: TA#: /077/-2 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: /000 gallons (per tank or cumulative for containers by product type) Install Date: ED ank (2820) ❑ Containers (2821) #of Containers: 'TA#: Oh Ila 7-7 1 (>250 gallons) (>55 gallons and<250 gallons) 2 �0� � Product Type: ,�� Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: L 0 6 gallons Total Capacity for Site: ZO c gallons Comments: EHD Inspector: Reviewed Date: ^ Entered Date: By Initial: �.`�l),4 By Initial: D EHD 28-01 01/16/08