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SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMENT • 0 East Main Street,Stockton,CA 95202-3029 Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Food F-npf'e!2� 2nG . Page--Lof Facility Address: City: [ns ection Date: 1250 E. Mtadru � 'Rc� . LCA\wc 0r3 (uehs' FA N: � PR#: D —'� Prograt0 Elpme_nt: Tank/Container Information �1-UY3 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: D616-!9�,?31 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Q) e4-QJ Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: I TA#: _ V 6 (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: q-00 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<50 gallons) 4 Product Type: _ Total Capacity: 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) 5 Product Type: Total Capacity: gallons - (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewedte: Entered Date: By Initial a By Initial: EHD 28-01 �Vf/nI� .I,SII (n1�1,.6Y�V(` 01/16/08