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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEl 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: •f np 1. /� Page e of j$� lily� (/vi►., /'� Facility Address: City: Inspectio Date: / Zoo S• 2 O FA#: PR#: ProgAm Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1320 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#: (>250 gallons) (>55 gallons and<250 gallons) 1ov Product Type: �,�_S' Total Capacity: OL-4' gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: t961 PZ,75 11 (>250 gallons) (>55 gallons and<250 gallons) 2 Da D Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: LR'Tank(2820) ❑ Containers (2821) #of Containers: TA#: _l (>250 gallons) (>55 gallons and<250 gallons) /N 3 �] Product Type: J'T .E � 1 L s ir) ✓ 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) 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 Z t'� gallons Total Capacity for Site: S Z �G j) gallons Comments: A/0 7-/h/ 5--P If 6//cl C A nJ EHD Inspector: Reviewed L Entered Date: p By Initial: LA By Initial: EHD 28-01 N/I t4 Gl I v I t o 01/16/08 (((