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SAN JOAQUIN COUNTY IVIRONMENTAL HEALTH DEPARTMENT ovo 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: fo &T) Page of Facility Address: City: lnsp '..n]pate: 55-5 �• r�� ,J ST 1.17/1 s'0� FA#: PR#: Progra Elgrtnt: o S3 Sys 9Y S 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 Product Type: 1 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) 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Cont 'hers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Produc Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Inst Date: ❑ Tank(2820) ❑ Containers (2821) /Install f Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 duct Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Date: ❑ Tank(2820) ❑ Containers (28 ) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 ga ons) 5 Product Type: Total Capacity: g Ions (per tank or cumulative for containers by produc type) Install Date: Total Capacity this Page: gallons FTotai Capacity for Site: gallons Comments: Sb Z �a 11t-1A c- 0 o Goy v l •V�ss+ -- cU k T CA Z4 221 C A 9s EHD Inspector: Reviewed Date: Entered Date: C . By Initial: w tl (6.b'Orb By Initial: Q 7 EHD 28-01 01/16/08