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SAN JOAQUIN COUNTY 'ENVIRONMENTAL HEALTH DEPARTMEN s o00 East Main Street, Stockton,CA 95202-30 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: `✓ 0 Page of Facility Address: City: Inspection Da e• O Fi'T C 5` r�� D d FA#: / PR#: Program Elem nt 001 �f 4 .-Z? g �i ? Zg327 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#: 196D 7AQ7 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: C d O 6z3 gallons (per tank or cumulative for containers by product type) Install Date: C�Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: Z O D d 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) 3 Product Type: Al 19- %ZO d G Total Capacity: s 4 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) E11C<ntainers (2821) #of Containers: �-- TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: � Total Capacity: 1112 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) EContainers (2821) #of Containers: TA#: &*9j ) -7jQf (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: T/�hj r✓,1' �� lJ Total Capacity: TS gallons (per tank or cumulative for containers by product type)1 11 Install Date: Total Capacity this Page: 2 (5 G gallons Total Capacity for Site: 2,1 b S~ gallons Comments: - EHD Inspector: Reviewed Date: Entered Date: By Initial: ��..4 By Initial: EHD 28-01 01/16/08