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SAN JOAQUIN COUNTY vENVIRONMENTAL HEALTH DEPARTMENJ 600 East Main Street,Stockton,CA 95202-3021T Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM F.aary Nam: 7-A p r_- G CfIAl27'e, 12 Page 2--of Facility Address: © i [mpecfioq Date: —. FA#: I PR#: Program Ele t: 5 8 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons inMainers over 55 gallons. Com Tete one box for each tank or each cumulative container roduct ❑ Tank(2820) Containers (2821) #of Contair= TA#: &-3-723,639 (>250 gallons) (>55 gallons and<250 gallons) ( Product Type: 9A/L D/ L/ Total Capacity: S.S gallons Install Date: or cumulative for containers by product type) Tank(2820) ❑ Containers.(2821) #of Containers: TA#: 1951 735/ (>250 gallons) > 50 gallons) nn � Product Type: Total Capacity: Ilons (per tank or cumulative r con ent type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #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: TAM (>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 (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: Q C) s S gallons Total Capacity for Site: gallons Comments: EHD Inspector: n Reviewed Date: Entered Date: B L.— r By Initial: By Initial: EHD 2MI 01/l6/08