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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN 600 East Main Street,Stockton,CA 95202-SU29 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: (/&L ,p '' U �, del/ / 1AIA Page O of / Facility Address: city- InsRR[i Dyfte: A94 C-oN .ZSno / �/v 6 �6 r FA#: PR#: Program Element: o© o / 6S p 2 $ 3 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. ^ L Complete one box for each tank or each cumulative container product type. IB�fank (2820) ❑ Containers (2821) #of Containers: TA#: (�c��(e aV, (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 1i .f Total Capacity: / O 4 gallons (per tank or cumulative for containers by product type) Install Date: Ql,Ifank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: /*0 o d 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: rt'�Plel gallons (per tank or cumulative for containers by product type) Install Date: Ql,,-fank (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: C/Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: GA,� Total Capacity: ` e�" gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this 9 Q gallons Total Capacity for Site: 17, gallons Comments: v EHD Inspector: Reviewed Date: Entered Date: C. By Initial: �� j-�� By Initial: r, EHD 28-01 l L 01/16/08