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SAN 40AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT . 600 East MainStreet, Stockton,CA 95202-3029:` � Telephone:(249)468-3420 Fax: (209)468-3433 Web:.www.sjgov.ozg/ehd . ABOVEGROUND PETROLEUM STORAGE'PROGRAM SURVEY FORM f - Facility Name: i--- c f✓ . U/ r Page of Facility Address: Pty, Inspection ate: FA#: PR#: Program Element: Tank/Container Inforimation Complete for all sites with cumulative aboveground storage of petroleum 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative'container roduct e.- ❑ Tank(2820) C�ontainers (282 1) #of Containers:' F� A TA#.:" (>250 gallons) (555 gallons and<250 gallons) 1 Product Type: ��y.�C'1�/,l C, Total Capacity: gallons Install Date: F (per tank or cumulative for containers by product type) f � � ❑ Tank(2820) 'Containers (282 1) #of containers. / TAM l (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type d/�fZ . &I L/ Total Capacity: �_gallons_ (pertank or cumulative for containers byproduct type) Install Date' ❑ Tank(2820) ❑ Container`s(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: TA#: (>250 gallons) (>55 gallons and X250 gallons) 4 Product Type: 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: -gallons (per tank or cumulative for.containers by product type) Install Date' Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: �- / ;ir 6/h CS %4.. r 4 E �AClZ h 3 7-0 ,✓S F - _ EHD Inspector: Reviewed Date! Entered . Date- By Initial: . 1 A _ ioBy Initial: EHD 28-01 v v. 01/16/08