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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME .,00 East Main Street,Stockton,CA 95202-30/-- Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name- J _ �� I K 0 i5, V,q L r d GO L (r✓�Vi LCA C-A F' Page-L—of l Facility Address: City: Inspe tion Da : 13 S" t l /-t,/Ix . o,' T 5 zz a g FA#: PR#4 Program Element: I S 2? 7 t-,/I Z? �v 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 (2821) #of Containers: TA#: t7` (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: tl0 o D gallons (per tank or cumulative for containers by product type) Install Date: 1C/Tank (2820) ❑ Containers (2821) #of Containers: TA#: d,f / (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: J�� Total Capacity: *Op gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: / ^)ltc3471:9— (>250 gallons) (>55 gallons and<250 gallons) ' 3 Product Type: 6—,9,S Total Capacity: / 3 0 d gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2-1 D�D gallons Total Capacity for Site: � � O gallons Comments: Loe - O' /V. � d EHD Inspector: Reviewed Date: / Entered Date: By Initial: V ,� �.'L1�Ub By Initial: EHD 28-01 01/16/08