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JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEP i00 East Main Street, Stockton,CA 95202-3( Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: IqL Po we L I! T I . v G k I t* Co Page of Facility Address: City: Inspe n ate: 2 C- T VIZ s CA 6JA1. a 8 FA#: PR#: Program Element: s-2 �6� -,2 -��v 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 e. 2 Tank(2820) ❑ Containers (2821) #of Containers: TA#: 1 (>250 gallons) (>55 gallons and<250 gallons) Product Type: ' (�O 9 R G e: Total Capacity: / U gallons Install Date: (per tank or cumulative for containers by product type) 2Tank(2820) ❑ Containers (2821) #of Containers: TA#: a6l&2 33� 2 (>250 gallons) (>55 gallons and<250 gallons) 20 O� Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) CD,I1 ank(2820) ❑ Containers (2821) #of Containers: TAM ,�f/X 3 C3(P 3 (>250 gallons) (>55 gallons and<250 gallons) ,/ r Product Type: ,/y Total Capacity: r gallons Install Date: (per tank cumulative for containers by product type) ank (2820) containers (2821) #of Containers: �_ TAM ��LO 3 50 gallons) 55 gallons and<250 gallons) 4 Product Type: L,i�4 S�� o j Total Capacity: ;Z-0 gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) Containers (2821) #of Containers: y TAM5 50 gallons) (15 gallons and<250 gallons) 5 3� Product Type: Total Capacity: gallons (per tank or cumulative for ontainers by product type) Install Date: Total Capacity this Page: Z 3 3 p gallons Total Capacity for Site: gallons Comments: ` g o w �2-0 O Esc A Z.vi'✓ A L�� N EHD Inspector: Reviewed Date: Entered / Date, + By Initial: By Initial: /! ),. 5-0A-T— L) EHD 28-01 1 01/16/08