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SAN JOAQUIN COUNTY ENVIRONMENTAL 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: 1,15 1 6; )1< A5 S Page of Facility Address: it Inspection Date: i �(_ (? *2- _Z_ 12zq'L1_T&f ci@ / -zNlo 9 FA#: PR#: Program"'---�• ; - Z F30 If 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. Tank(2820) ❑ Containers (2821) #of Containers: TA#: 7 IQ$T (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: gallons (per tank or cumulative for c tamers Fy product type) Install Date: CP'Tank(2820) ❑ Containers (2821) #of Containers: TA#: V7!- '25- (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: 100V 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: 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: j 3 gallons FTotal Capacity for Site gallons Comments: EHD Inspector: 1 Reviewed Date: Entered Date: (' By Initial: VvfJ a,O),Q By Initial: EHD 28-01 01/16/08