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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 4600 East Main Street, Stockton,CA 95202-30 9 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r y ,0 P4 d P Page of Facility Address: City: Inspect! n Date: a/ Gv G/'Vc /y La y FA#: PR#: Program Element: O 00 4L © r1j- 7 Y.5 -' I 2-S3 -1-1 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 (282 1) #of Containers: TA#: 5J5 (>250 gallons) (>55 gallons and<250 gallons) o 1 Product Type: Total Capacity: 4 0 C7 0 gallons (per tank or cumulative forntainers by product type) Install Date: ❑ 196Tank(2820) Containers (2821) #of Containers: l TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: G//I Total Capacity: Cp gallons Install Date: (per tank or cumulati for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ 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: U .5-r) gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Dat : Entered f/n Date: (711 By Initial: ✓ By Initial: EHD 28-01 01/16/08