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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME 600 East Main Street, Stockton,CA 95202-3Uz9 Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: ' 1i T Co T �R r Page of Facility Address: City: In77Date FA#: PR#: Program Element: Z z 6 sL 2- Tank/Container Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ;2t gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. �jank(2820) ❑ Containers (2821) #of Containers: TA#: Nn,J ,q7 T (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: /Doa gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 4?�J&175 (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: & �/�,f Total Capacity: S a b 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) / Total Capacity: d U gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: t TA : /� l��i 7 ?_ (>250 gallons) (>55 gallons and 1250 gallons) 4 Product Type: (/ Total Capacity: Od gallons (per tank or cumulative fo ontainers by product type) Install Date: ❑ Tank (2820) k> galIontainers (2821) #of Containers: TA#: � �Z - 0 (>250 gallons) ons and 1250 gallons) / 5 Product Type: Q/ C� Total Capacity: b/ a gallons (per tank or cumulative r containers by ptoduct type) Install Date: Total Capacity this Page: EE19 gallons Total Capacity for Site: ZI d Q gallons Comments: 2 3 b 7e EHD Inspector: Reviewed Date: 0 6 i Entered Date: --� By Initial: �.�0 By Initial: EHD 28-01 01/16/08