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SAN JOAQUIN COUNTY Y I ENVIRONMENTAL HEALTH DEPARTMEN' 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facilit Ngxe• C /1 / Cr0 /VG C (/j C C O Xfi Page _� of Facility Address: C•ty Inspectii000n Date:_ FA #: PR #: 0 6Ad?o ZI Program Element: -Z,330 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_ 1320 gallons in tanks and containers over 55 gallons. Ar Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: &)51-7 62 �5- 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type:�p,�? p Total Capacity: 'Zgallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 19 2 _ (>250 gallons) (>55 gallons and <250 gallons) ' Product Type: 6z� Total Capacity: 300 gallons (per or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: B 6 • / -712 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: GIR,5 Total Capacity: D 6 gallons (per k or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: / `7 (>250 gallons) (>55 gallons and <250 gallons) 4 i Product Type: �,,�P�,.e� Total Capacity: b Pgallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: f Q gallons Total Capacity for Site: 3 .9 gallons Comments: EHD Inspector: ✓ Reviewed Date: ''// By Initial: p ,11,A Entered Date: By Initial: EHD 28-01 01/16/08