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SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTME1 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: � /? � GGr� t�J'vd12 C Page of Facility Address: City: Inspec7-sz Date: Irz-00 S• FA#: PR#: ProgArn Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1320 gallons in tanks and containers over 55 gallons. 1/1 Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: Z00'd gallons (per tank or cumulative for containers by product type) Install Date: EP/Tank(2820) ❑ Containers (2821) #of Containers: TA#: B51 D Q (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: J-d "`5'O gallons (per tank or cumulative for containers by product type) Install Date: LTJ'Tank(2820) ❑ Containers (2821) #of Containers: TA#: e5Q/ l (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: J'-r.9 bt i li YY Total Capacity: �a� 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: s gallons Total Capacity for Site: S Z $�Cd gallons Comments: C A AJ k EHD Inspector: ReviewedEntered Date: By Initial: i 6� By Initial: 1�/0 EHD 28-01 V 1 01/16/08