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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMET 600 East Main Street,Stockton,CA 95202-30 , Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r%j P O v rE )J 5 Ci o Page J of Facility Address: City: Inspectio 500 l P S7 - ;Date:>o FA M PR M Program Element: 0 0 o z.i Y v z 8 3 -1.- 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 type. ITank(2820) ❑ Containers (2821) #of Containers: TA#: 19511,71 250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: 90y0l6 gallons Install Date: (per tank or cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: TA#: ;Z0 (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: 12zO Total Capacity: /O D o gallons Install Date: (per tank or cumulative for containers by product type) WYTank(2820) ❑ Containers (2821) #of Containers: TAM /9?5-1& l02 (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: lad 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) r ) q Product Type: l/ Total Capacity: 15e9o 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 Install Date: (per tank or cumulative for.containers by product type) Total Capacity this Page: f) gallons Total Capacity for Site: gallons Comments: EHD Inspector: r Reviewed e: Entered Date: By Initial: By Initiate B EHD 28-01 01/16/08