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SAN JOAQUIN COUNTY 's ENVIRONMENTAL HEALTH DEPARTMEP 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 N me: Pa e Of /= S o n/ C LiN�s �t✓ C) g Facility Address: City: Inspe tion D te: 19 3" A/0- CA 9 3 0 QS FA#: PR#: Program Element: Szez 1 D5,2 g 72 7 -z,8 © 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#: (>250 gallons) (>55 gallons and<250 gallons) 1 �C2� Product Type: i/i/A S TF O 111 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) C 2 Product Type: /�j U�0� O/C Total Capacity: S 1� 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) 3 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) 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: 7 gallons Total Capacity for Site: '7 q-07 gallons Comme AA171 /C EHD Inspector: r Reviewed Date: Entered Date: By Initial: � By Initial: EHD 28-01 01/16/08