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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT t 00 East Main Street,Stockton,CA 95202-302 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: '(\h LL Page t Of f /A Inspection Date: ,G City: Facility Address: P f- ' fes. " 1/1/ �/V Program?Element: FA#: IL#: Z 0 7 q4101 I6 Tank/Container Information # Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. Com lete one box for each tank or each cumulative container product e. El Tank(2820) Containers (2821) #of Containers: l TA#: t (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 2-.SO gallons Install Dater (per tank or cumulative for containers by product type) ❑ Tank(2820) 2111,aontainers (2821) #of Containers: Y TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: /G Total Capacity: P 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<250 gallons) 3 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) 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. (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 3 ogallons Total Capacity for Site: 3 d gallons Comments: /�.ZC7 A Df�I 4 ' EHD Inspector: ReviewedDate: Entered Date: 4 By initial: { v, { p�ftp By Initial: r �+ d' D EHD 28-01 01/16/08