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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax (209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: S-A 4/ -3-0Atlll✓ /��`�l d f1/� �i A11` I Page of Facility Address: City: Inspection Date: Z.d 11/ / � 1 51- S im /r 3 �,* FA#: � � PR#: ' Program dement: G. 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#: (>250 gallons) (>55 gallons and<250 gallons) 1 1' Product Type: /11 Cy of l✓ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: TA#: j�?5 0 A13 ,E ,E (>250 gallons) (>55 gallons and<250 gallons) ' 2 / Product Type: Total Capacity: U gallons (per tank or cumulative for containers by product type) Install Date' — ❑ Tank(2820) E5'Containers (2821) #of Containers: _ TA#: ? j (>250 gallons) (>55 gallons and<250 gallons) 3 ,,, Product Type: �10 Jam- ai Total Capacity: S gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 galldns and<250 gallons) 4 � S 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 Pag' gallons Total Capacity for Site: gallons Comments: I EHD Inspector: Reviewed Date: Entered Date: By Initial: By initial: r� EHD 28-01 01/16/08