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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM 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 " FacilityName: n L G Q � 7-/? vGK f /, ' �� j,) /'y �(/� (r- Page of Facility Address: City: Inspection ate: ✓ 3r6 S� C� 7 FA H: PR#: Progra Element- ,,95/-74 j Do I eel I g' Tank/Container Information Complete for all sites with cumulative aboveground s rage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Complete one box for eacq tank or each cumulative container product ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: gallon (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (282 ) #of Containers: TAM(>250 gallons) (>55 gallons and<250 gall s) 2 Product Type: Total Capacity: gal ns (per tank or cumulative for containers by product e) Install Date: ❑ Tank(2820) ❑ Containers( 821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: allons (per tank or cumulative for containers by prod t type) Install Date: ❑ Tank(2820) ❑ Contain s (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons an <250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Co ainers(2821) #of Containers: TA#: (>250 gallons) (>55 gal ns and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for con finers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: /I#71,1JCS EHD Inspector: Reviewed _+ Date: / Entered Date: By Initial: VA tib By Initial: 7 V EHD 28-01 u 01/16/08