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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: O C Page � ofA al-i A � Facility Address: City: lnspe tion ate: 6 3 / C)S q o FA#: PR#: Program lement: OD / 01 0�L 3"ZzI0-- I E :? 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. 0-- ank (2820) ❑ Containers (2821) #of Containers: TA#: ©csl�02RJ� (>250 gallons) (>55 gallons and<250 gallons) ' 1 Product Type: /Ja.Fj� Total Capacity: p D gallons (per tank or cumulative for containers by product type) Install Date: 2/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1216 J (� (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: sUlJ gallons (per tank or cumulative for containers by product type) Install Date: [Tank(2820) ❑ Containers (2821) #of Containers: TAJ: i9 (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: O .0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: B53 62a2c.g (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: / O gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 9-c-ontainers (2821) #of Containers: TAM /9 /,�e S (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: 1 Total Capacity: yO' gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 70 Q gallons Total Capacity for Site: 7 O Z,-rD gallons Comments: EHD Inspector: ReviewedDate: LO QQ Entered Date: By Initial: By Initial: EHD 28-01 01/16/08