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"• " SAN.IOAQUIN COUNTY . IRONMENTAL HEALTH DEPARTMENT 00 East Main Street,'.Stockton,CA 95202-302 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd k ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: .-- Page_L/_of L°, / � A 5'a v 1 S�h C�M n 7- Facility Address: ;City- inspection D te: �Z v ! W W4 5 � o>y S r i �� . FA#: PR#• Program Element: 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,ea cumulative`co/ntainer product e. ❑ Tank (2820) ontainers (2821) #of Containers: -_6 --- (>250 gallons) {>55 t ' " ��r n aallnnsl.. 1 3Product Typ S7" . .a�. Total Capacity: ' gallons (per tank or cumulative for conwmers oy product'type) Install Date: ." "nk(2820) C] Containers (2821) #of Containers: .• . 'TA#: . (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: Z. O gallons (per tank or cumulative for containers by product type) Install Date' ❑ Tank(2820) ontainers (2821) #of Containers: Il TAM , (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: _ y -y,;fp I- Total Capacity:. 55 gallons _{ Install Date-.. (per tank or cumulative for containers by product type) ❑ Tank(2820) L�<ontainers (2821), . #of Containers: _ TAM (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: G�'Xl2 Of Total Capacity: gallons $ (per tank or cumulative for containers by product type) Install Date' ❑ Tank (2820) ontainers (2821) #of Containers: TA#: (>250 gallohs) (>55 gallons and<250 gallons) 5 Product Type: /1 P'rP/U d� Total Capacity: gallons (per,tank or cumulative for can Install Date:niers by product type} , Total Capacity this Page: gallons Total Capacity for Site: 6 gallons Comments: 2-0 EHD Inspector: Reviewed 1 Date: / Entered Date: By initial: t' �I /7v lDt_�[v� By Initial- 'g EHD 28-01 v" 1 01/16/08 * s