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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT *-tf00 East Main Street,Stockton,CA 95202-302f4 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: EA L ) r- w- N1 M l L Afv0 Page of / Facility Address: City: Inspectio Dolt: 2 Zo s 1^rPT0 )✓ FA#: 13 6 lPR#: Program Ele en: O - 28 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Co lete one box for each tank or each cumulative container product ❑ Tank (2820) Containers(2821) #of Containers: ��TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: `q/fi S TG7 0 Total Capacity: l/ gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: Z- TAM (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: 1"D TD 2 O Total (per tank ore emulative for containers by product gallons U'/Containers(2821) � Install Date: ❑ Tank(2820) Its Containers(2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) Type: Y �� A L/ G P 3 Product T e: Total Capacity: / / 0 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) 4 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) 5 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 3 3O gallons Total Capacity for Site: gallons Comments: L EHD Inspector. �1� Reviewed Date: Entered Date: By initial: 1 s�� G�,(�j (J�j By Initial: EHD2"1 OIIINO8