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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN 600 East Main Street, Stockton,CA 95202-3u29 Telepnone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name,!� _ y(? CA/ ��/� i ��.f L /�`� r Page of Facility Address: City: Inspect' n e• FA#: �r PR '5-� � / Program El-1-2- Tank/Container Information !'e e 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. EN/Tank(2820) ❑ Containers (2821) #of Containers: TA#: Q_Cj J t'.v 7 I (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: CJ-O gallons (per tank or cumulative for containers by product type) Install Date: CYTank (2820) ❑ Containers (2821) #of Containers: TA#: D (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: -52 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 7a-7-1 (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: PAO O ,DI Total Capacity: *I- gallons ' (per tank or cumulative for containers by product type) Install Date: (2820) ❑ Co (2821)T #of Containers: TA#: z95 j/v 7A -V- (>250 gallons) (>5 allons and<250 gallons) / 4 —D Product Type: d Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Cgntainers (2821) #of Containers: TA#: D51 Lp72, �5 (>250 gallons) (> gallons and<250 gallons) r- �� 5 �©0 Product Type: 1y/4 I/ � Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: — 13U0 gallons Total Capacity for Site. 'D gallons Comments: Cz� 7 t 5d . 2ll6-As ow 40 HAciv- o 1 (Z-921) I 2 a r- 6- L/ EHD Inspector: Reviewed Date: ✓I Entered Date: By Initial: I_.1 By Initial: ///// 67 EHD 28-01 01/16/08