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SAN JOAQUIN COUNTY —ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-302 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: `� �A L / f y Page _160f Facility Address: City: Inspection Date: FA #: PR #: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1320 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#: Q J1v�7�0 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: �SJ�� p/ l/ o Total Capacity: �o gallons (per tank or cumulative for containers by product type) Install Date: Containers (282 1) ElTank (2820) Z/ #of Containers: TA#: % 2 (>250 gallons) (>55 gallons and <250 g Ilons) � Product Type: vt Q -i Total Capacity:'-" gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) C1 Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: p gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: /2H l LQ q 7 4�� (>250 gallons) (>55 gallons and X250 gallons) ��✓ Total Capacity: Product Type: j� gallons Install Date: (per or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Gt/�4.1'�.� �! Total Capacity: /0 0e) gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 !�,/_ �� gallonsl Total Capacity for Site: gallons Comments: EHD Inspector:Reviewed / Date: By Initial: Entered Date: By Initial: EIt EHD 28-01 B 01/16/08 kc