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SAN JOAQUIN COUNTY hENVIRONMENTAL HEALTH DEPARTI,ft 600 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: 6�� X Page 'L of Facility Address: City: Inspectio Dat 6 8 %%z FA #: PR #: Program Element: 7 l z9 — o2g3 --z- Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum > 1320 gallons in tanks and containers over 55 gallons. Com to one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (282 1) #of Containers: TA#: 96-1& 7690 1 (>250 gallons) (>55 gallons and Q50 gallons) �. Product Type: f�l//4 STS' A 7/ i::�%1rf7z� Total Capacity: / D 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) 2 Product Type: Total Capacity: 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) 3 Product Type: Total Capacity: 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) 4 Product Type: Total Capacity: 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: gallons FTotal Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered DatZ17i By Initial: By Initial: L9U EHD 28-01 01/16/08