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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME. 600 East Main Street, Stockton,CA 95202-30/-9 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / t (� I� 11/ /,1/✓j/ GT �/2.C1✓ 110 Page_L—of Facility Address: City: Inspec on at 19sZ7 C11A-Alk � V ,sem �� FA#: PR#: Prograni Element: Q6Dl>D -ex I a � 83� 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 (282 1) #of Containers: , TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: ---' D a gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) M-Cl ontainers (2821) #of Containers: o TA#: d — (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: yze(R Total Capacity: 3-30 gallons (per tank or cumulative for containers by product type) Install Date: C?"fank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: 6�-'q,J' Total Capacity: r''e D gallons (per tank or cumulative for containers by product type) Install Date: f[ank (2820) ❑ Containers (2821) #of Containers: -, T0A/#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: '2-v ' 'S gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (282 1) #of Containers: TA#: t-j/ (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: Z ' D gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons FTotal Capacity for Site: gallons Comments: G EHD Inspector: Reviewed Date: Entered Dat C By Initial: UAJ �,j l7 (7� By Initial: J� EHD 28-01 01/16/08