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SAN JOAQUIN COUNTY 1NVIRONMENTAL HEALTH DEPARTMD o00 East Main Street, Stockton, CA 95202-302> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: j / C. (1 .01 D / iv �' IAI G ' Page of Facility Address: City: Inspectio e• v ��- ZATW�a , y FA#: PR#: Program Element: as o5 -� Ro 'i Z_ g - � Tank/Container Information Complete fo 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#: �0 D� (>250 gallons) (>55 gallons and<250 gallons) 1 � Z C) � d Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4, [ [ (>250 gallons) (>55 gallons and<250 gallons) r 2 Product Type: Total Capacity: 3 ° gallons (per tank or cumulative for containers by product type) Install Date: G2' Tank (2820) ❑ Containers (2821) #of Containers: TA#: 60&11 (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: �jp,S T.� C>/ � Total Capacity: ,j o D gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) P"Containers (2821) #of Containers: TAM (9 S"/(P / / , (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: 11O gallons (per tank or cumulative for containers by product type) Install Date: WTank(2820) 9/containers (2821) #of Containers: TA#: 0�5_/to ((--:3 (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: /I O gallons (per tank or cumulative for containers by product type) Install Date: '2-d Total Capacity this Page: gallons Total Capacity for Site: 3 ZD gallons Comments: Off y059,M ATE T5'- t2-0 EHD Inspector: Reviewed te: Entered Date: / v By Initial: By Initial: rQ EHD 28-01 01/16/08