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SAN JOAQUIN COUNTY INVIRONMENTAL HEALTH DEPARTMENT 'fta6)East Main Street,Stockton,CA 95202-302 Telephone.(209)468-3420 Far.(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / t✓l T 0 LOP;P/ E u,- Page--/—of Facility Address: Cf luspecti0 D e: z S 1tiB2. SA C, $ FA#: PR#: Program Element• S S S — � 2 g ){-b 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 Tank(2820) ❑ Containers (2821) #of Containers: ✓TAM (>250 gallons) (>55 gallons and Q50 gallons) ,� "/� 1 Product Type: 7/A�a-�c� Total Capacity: 30n gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers(282 1) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons (pa 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 Install Date: (pa tank or cumulative for containers byproduct type) - - ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons Install Date: (pa tank or cumulative for containers by product type) - Total Capacity this Page: �� gallons Total Capacity for Site: 3 G6 gallons Comments: < / A loy✓_f EHD Inspector Reviewed Date: Entered Date: By Initial: q,a-o1S By Initial: S! EHD 2"1 01/16/08