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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 600 East Main Street, Stockton,CA 95202-3,._j Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: �'0/lS Pot. G A S / Page / of� Facility Address: city: Inspec io Elt Z >� Zea C e ,o FA#: PR#: Program Element: 05x8 0 _ z4 3 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z 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#: 1p (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: / O V D gallons (pr tank or cumulative for containers by product type) Install Date: FreTank 2820 ❑ Containers 2821 ( ) ( ) #of Containers: TM: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: 2 O d gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 3 �� Product Type: AE Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) E?/6ntainers (2821) #of Containers: ZTA#: (>250 gallons) (>55 gallons and<250 gallons) 4 + � Product Type: Total Capacity: l gallons Install Date: �21/bu� (per tank or cumulative for continers by product type) ElTank (2820) Q"Ca�ontainers (282 1) #of Containers: TAM (>250 gallons) > 5 gallons and<250 gallons) 5 0 �j Product Type: f t-_ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: /, 6r l gallons Total Capacity for Site: gallon Comments: V EHD Inspector: Reviewed Date: Entered Date: By Initial: ) (.(L V f By Initial: EHD 28-01 L Gf 01/16/08