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SAN JOAQUIN COUNTY ,NVIRONMENTAL HEALTH DEPARTMENT 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 Facility Name: 111T �-. �J 0 �� / z G7 Page of Facility Address: C' Inspection D te: FA#: PR#: Program ElemeD t: " 5) q 3 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Melank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 0�..,t..Pi��*� Total Capacity: I" gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TAM B`S/ (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Y� Total Capacity: C Kl47 gallons (per tank or cumulative for containers by product type) Install Date: 1000fak(2820) ❑ Containers (2821) #of Containers: TA#: 1 1 (>250 gallons) (>55 gallons and<250 gallons) i� � 3 ?- Product Type: Total Capacity: 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) 4 Product Type: Total Capacity: 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) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: f r �94 gallons Total Capacity for Site: gallons Comments: EHD Inspector: /� Reviewed Date: Entered Date: (,� � By Initial: ` ,I� t�,L(-0 By Initial: EHD 28-01 v 01/16/08