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SAN JOAQUIN COUNTY ' :NVIRONMENTAL HEALTH DEPARTMEN" ,,00 East Main Street, Stockton,CA 95202-302> Telephone:(209)468-3420 Fax:(209)468-3433 Weh:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page of Facility Address: City: ✓ Inspectio Date: o S O . Glq/� P/✓T�1Z �� 7? 14 p FA#: PR#: Program Eleend 3 �v o - 1,13` 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 type. Tank(2820) ❑ Containers (2821) #of Containers: TA#: 0,5-) �p (>250 gallons) (>55 gallons and<250 gallons) 7_10— 1 Product Type: �L'n S(_ L Total Capacity: 4 6 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) P'Containers (2821) #of Containers: t TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: 111 ,07-0/2. �jl Total Capacity: -Z S 0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) containers (2821) #of Containers: v TA#: j9,!5_1 7 � (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: 6;e/1 Total Capacity: // 0 gallons (per tank or cumulative for conta' ers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: 3 TA#: (>250 gallons) (>55 gallons and<250 gallons) ' 4 Product Type: !J'A�� 0.1 (/ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) &Containers (2821) #of Containers: ^_')�/TA#: B (>250 gallons) (>55 gallons and<250 gallons) 11 5 Product Type: �l Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page:/�� gallons Total Capacity for Site: ZQ �� gallons Comments: /�0 5.Z� EHD Inspector: 1J Reviewed Date: Entered Date: By Initial: vi " By Initial: EHD 28-01 01/16/08