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SAN JOAQUIN COUNTY `rNVIRONMENTAL HEALTH DEPARTMENT 6W East Main Street,Stockton,CA 95202-302ONNO Te%phone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.orgtehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Nance: Page—L—Of G�� l/�LK.S l Facia Address: ty: Inspect n Dat 2 / f� .� HSM �� L-11? sT r7o a FA#: PR#• Program Element: 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 ff'Tank(2820) ❑ Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 19(�6 0 gallons Install Date: (per tank or cumulative for containers by product type) - L5-tank(2820) ❑ Containers (2821) #of Containers: . TAM (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: b 1 Total Capacity: 3 Q v gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TAM (>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 (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank w cumulative for containers by product type) Install Date: Total Capacity this Page: 00 gallons Total Capacity for Site: ? 0 U gallons Comments: '37 /NAG? EHD Inspector Reviewed Date: Entered Date: By Initial: u� -1,1r1.of By Initial: la M EHD 28-01 01/16/08