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SAN JOAQUIN COUNTY 1%W. ENVIRONMENTAL HEALTH DEPARTM 600 East Main Street,Stockton,CA 952029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility.'Jame: �11floc n©/J Iv U`/ 1 r„// Page /J e of Facility Address: C Insp Da ,/ S/ AGM0P100v 0D /'i MAr✓'7',6CA n FA#: PR#: Prno-- —,^ ent: 1 5-/ T ? :Z $*3 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product Tank(2820) ❑ Containers (2821) #of Containers: n TA#• l95/[�7✓�O (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: / 000 gallons Install Date: (per tank or emulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: TA#: 06-1/e 7� 7 (>250 gallons) (>55 gallons and<250 gallons) /- 2 Product Type: /Y�j — Z7 Total Capacity: / j2 _gallons stall Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons 'Install Date: (per tank or cumulativ for containers by product type} Total Capacity this Pag ZrJ gallons Total Capacity for Site: 'Z��/ gallons Comments: EHD Inspector: Reviewed1 DaIte: Entered Date: By Initial: WN w.1,1-0$ By Initial: EHD 2"1 01/16/08