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SAN JOAQUIN COUNTY NVIRONMENTAL 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 Facility Name: Pa ,�// �-p �- C- At OK � / /�41 d G/f rl s ge - of Facility Address: �.� Inspection�Date: EV 6 3 � , GP %fir, /�/'�o 9//'r d g FA#: PR#: Program Element: ®�aagg V- z, g�� 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#: �* (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 0Lj 0 T- /'L 0 y Total Capacity: /) S 0 gallons l — (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) EP Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 / Product Type: rVj'0 �dn. Q � Total Capacity: !l D gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) L�'C;ontainers (282 1) #of Containers. , TA#: b '� 3 (>250 gallons) (>55 gallons and<250 gallons) Product Type: Total Capacity: / / 0 gallons Install Date: (per tank or cumulative for containers by product type) ❑ 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: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered d By Initial: By Initial: EHD 28-01 01/16/08