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SAN JOAQUIN COUNTY ?NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3025 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: "r� U G�t � Np Page _� of Facility Address: � City: /+ ,7 ///) Inspec�i/ q D FA #: loo 3 PR #: Au�g��o Progran4 Elet: grgg3 rtlen 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. P-fank (2820) ❑ Containers (2821) #of Containers: TA#: iP5/Le7 f 1 (>250 gallons) (>55 gallons and <250 gallons) / Product Type: Total Capacity: 2 0 5 v o gallons Install Date: (per tank or cumulative for containers by product type) R -T' ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: ?100 gallons Install Date: (per tank or cumulative for containers by product type) IP/Tank (2820) ❑ Containers (2821) #of Containers: TA#: d 5-/& l V 3 (>250 gallons) (>55 gallons and <250 gallons) ` Product Type: f� Total Capacity: / 2 Jr o 0 gallons �r Install Date: (per tank or cumulative for containers by product type) VTank (2820) ❑ Containers (2821) #of Containers: TA#: Q �,>2 -7y 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: p i Total Capacity: so o gallons (per tank or cumulative for containers by product type) Install Date: E?"'Tank (2820) ❑ Containers (2821) #of Containers: TA#: $ (>250 gallons) (>55 gallons and <250 gallons) Product Type: IQS' tJ Total Capacity: / o Q a gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 00 -% gallons p Total Capacity for Site: .�0 gallons Comments: EHD Inspect o Z ' Reviewed , Date: By Initial: �/+'' S.� Entered Date: By Initial: EHD 28-01 01/16/08