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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN r *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 EHD 28-01 01/16/08 Facility Name: dim Q.U\.S Cb Page of Facility Address: 14 70o w City: - S�,I -I-� � Tr�c� Inspection Date: FA #: F(APR o� #: P iq 6 X16 -3,27 Program Element: Tank/Container Information 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 product type. r% Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 (>250 gallons) (>55 gallons and <250 gallons) . Product Type: p! Total Capacity: q5b gallons (per tank or cumulative for containers by product type) Install Date: ��/ ❑ Tank (2820) rContainers '" (282 1) #of Containers: TA#: 2 (>250 gallons) 5 gallons and <250 gallons) Product Type: GN A4-QAQ_4f Z, Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 (>250 gallons) (>55 gallons and <250 gallons) 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 Total Capacity for Site: gallons Comments: -')_Ob "�' . 14'S'T-� ( o god 8 EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: EHD 28-01 01/16/08