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SAN JOAQUIN COUNTY "ENV IRONMENTAL'HEALTH DEPARTMENT 4F!-1600 East Main Street,'Stockton,CA 95202-30297- Telephone.- 5202-3029-Telephone:(209)468-3420 Fax:(209)468-3433`Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM E Facility Name: / /�Q Page l of US CSN r-- T - C 7 Facility Address: City: Inspectio Aa SS p G i G , _I/ I A re,10. �� 2D$ FA M. ! PR#: . , Program Element: Q: Tank/Container Inforination Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Com ete one box for each tank or each cumulative container product type.. ❑ Tank (2820) Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) i Product Type--- bV1q S r� Dr: — Total Capacity: l�7) .. gallons Install Date- (per tank or cumulative for containers by product type) ElTank(2820) E?``ontainers (2821). #of Containers: TA#: S (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: �fa S Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) U Containers (2821) #of Containers: TA#: 3 (>250 gallons) - " (>55 gallons and 0150 gallons) yp; D�� Product T e: y L/ Total Capacity: T // b . gallons In Date: (per tank or cumulative for containers by product type) ' ❑ Tank(2820) . O Containers (2821) ifflf Containers: 1— TAM (>250 gallons) (>55 gallons and X250 gallons) 4 Product Type: !Dw. D 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) 5 Product Type: Total Capacity: 560 gallons (per tank til cumulative for containers by product type) . Install Date: Total Capacityahis Page: ,S gallons Total Capacity for Site: S r gallons Comments: A ) 52-0A tYf/ .r . EHD Inspector: _ Reviewed Date: Entered lute: C- By Initial: . ,�� By Initial: 8 EHD 28-01 V 01/16/08 r