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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ,,00 East Main Street,Stockton,CA 95202-302> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Na 0 't,� /� &�o/ZPage of Facility Address: City: Inspectio Date: Ad FA#: PR#: Prograin Element: 1 o y3a 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. l� Tank(2820) ❑ Containers (2821) #of Containers: TA#: 6,,15-1 :2 7!? (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 1-) 0 0 0 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: B 6-) -] -7 ? (>250 gallons) (>55 gallons and<250 gallons) n 2 Product Type: �..-(�Z�x Total Capacity: Zb-C)19 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 0 0 gallons Total Capacity for Site: Z C2 0 to gallons Comments: EHD Inspector: /J Reviewed Date: Entered Date: �,p� By Initial: Vv' e}. C I I By Initial: n D EHD 28-01 OC 01/16/08