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SAN JOAQUIN COUNTY 'ENVIRONMENTAL HEALTH DEPARTMET 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 0 L)S /� SU'1.�. O _ Act � L -Page of Facility Address: 1 I City: Inspection Date: FA #: PR #: Progr m Element: 052�� 93 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product tvne. 7 Tank (2820) ❑ Containers (2821) #of Containers: TA#: (`>4250 gallons) (>55 gallons and<250 ]ions) 1 3 3 (Po t oo o Product Type: E qL' A, Tota Capacity: ga lons Install Date: (per tank or cumulative f nt coain by product type) Tank (2820) ❑ Containers (2821) #of Containers: TAM L,251,f�T� ee ft LSo2 (>250 gallons) (>55 gallons and <250 gallons) 2 30, o0o Product Type: Total Capacity: gallons tall DQ (per tank or cumulative for containers Insate: by product type) L / & 6 ❑ Tank (2820) Containers (2821) #of Containers: TA#: �7 (>250 gallons) >55 gallons and <250 gallons) 3 q 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: 55�J2� Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) �Q / Product Type: Total Capacity: [ �P F, 0 00 gallons (per tank or cumulative for containers by product type) Install Date: 5 L�Tank (2820) ❑ Containers (2821) (>250 gallons) (>55 gallons and <250 gallons) Total Capacity: 4, 3�'Ip, 000 gallons (per tank or cumulative for c nomtamers by product type) #of Containers: TA#: 3y % Product Type: 0—,r1 3 e5 OZ - Install Date: 7 0 Total Capacity this Page: = n gallons ITotal Capacity for Site: allons Comments:Z s Z— 2 -7 711 EHD } eviewed ! 1 Date: Entered Date: By Initial: \ 1 By Initial: ,(/n I EHD 28-01 01/16/08