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SAN JOAQUIN COUNTY :NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3025 Telephone: (209) 468-3420 Fier: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: I � 7' v Page —leof Facility Address: City: Inspection Date: FA #: PR #: Program Element: 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#: D,� /10c1710 1 (5250 gallons) (555 gallons and <250 gallons) Product Type: �S/-Q o Total Capacity: �o gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) L/ Containers (2821) #of Containers: TAM 2`,OS-/ jp! j 7 % (>250 gallons) (>55 gallons and <250 gallons) 2 Product Type: Total Capacity: / 3 b gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) C1 Containers (2821) ##of Containers: TAM ?t5 11Pq % 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: 1 -ire gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: /2 H 1 LP q 7 47 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: }P�r/ 0'e, Total Capacity: T U e gallons Install Date: (per or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0�-/ 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: �/Q.f'�� l Total Capacity: a � gallons ` Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 2 54L gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: By Initial: Entered Date: By Initial: V It LFa EHD 28-01 01/16/08