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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME. 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 Page of Facility Address: 9 .G� City: ICA Inspect' n ate: s 6 FA #: 00CF z PR #: 365- Program Element: 1 -z't-� 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 co tainer product type. Tank (2820) ❑ Containers (2821) #of Containers: #: Q51 1 1 (>250 gallons) (>55 gallons and <250 gallons) ^ n Product Type: N J Total Capacity: 1`0 U & gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers:_� TA#: Q,�� 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type:% Total Capacity: lO 0,062 gallons Utainens Install Date: (per tank or cumulative for by product type) ank (2820) ontainers (2821) #of Containers: TA#: 0 1(v 1 S 3 (>250 gallons) (>55 gallons and Q50 gallons) _� Product Type: (�/� f T� pl G Total Capacity: 2- .5 0 gallons Install Date: (per tank or cumulative for containers by product type) 2820) 1250 ontainers (2821) #of Containers: Y TA#: eo 1c 4 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: q o O gallons Install Date: (per tank r cumulative for containers by product type) "ank (2820) Ea,&ntainers (2821) #of Containers3 1' TA#: /9cj5___/ Ze 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: �G A/L �Ql� Total Capacity: /�,� gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallons FTotal Capacity for Site: gallons Comments: AI E Y ^I A TGlL/ L NrC EHD Inspector: C' � � ReviewedItro By Initial: f Entered Date: By Initial: f_ Z v EHD 28-01 01/16/08