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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEAQ - 600 East Main Street, Stockton,CA 95202-3029 Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: () IJ 17 Ti9 D Page of Facility Address: 'ty Inspection te: Z-9 r� � FA#: PR#: Program Elem nt: or 2-'? 3D 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#: Ze (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 60V Total Capacity: 1000 gallons Install Date: (per or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) / 2 Product Type: f Total Capacity: 5'n lI gallons (per tank or cumulative for containers by product type) Install Date: 09"fank (2820) ❑ Containers (2821) #of Containers: TA#: 0,51-7 (fl'7 (>250 gallons) (>55 gallons and X250 gallons) 3 Product Type: 619 S / Total Capacity: O a gallons Install Date: (per tank or cumulative forr containers by product type) 5;�4ank(2820) ❑ Containers (2821) #of Containers: TA#- (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: S p-D 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: 16roygallons Total Capacity for Site: gallons Comments: s EHD Inspector: Reviewed Date: Entered Date: By Initial: kxAj 1''..17.0W By Initial: 4/ EHD 28-01 01/16/08