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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEI 600 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: ZbF�12 /gJ'U7/Ie G Page of Wrz Facility Address: City: Inspectio Date: FA#: tP : Pro m Element: 114 6n �(I o,,-� � 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#:D, 1-1 (>250 gallons) (>55 gallons and<250 gallons) 1ero Product Type: Total Capacity: ©10' gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and QSO gallons) 2 Id, D& D Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: EP Tank (2820) ❑ Containers (2821) #of Containers: TA#: r (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: J're 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: -5,2- gallonsFotalCapacity for Site: S Z j gallons Continents: Al C_ k1 A EHD Inspector: Reviewed to Entered Date: p By Initial: ��(�_ By Initial: J W / EHD 28-01 G Wlo J�v ` 11' V (Q Yl/C f fn01/16/08 l vl /� � �(