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SAN JOAQUIN COUNTY 0NVIRONMENTAL HEALTH DEPARTMENTS i '500 East Main Street, Stockton,CA 95202-3029gw' �I Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY."FORM , Facility Name: ! M �l N1c3N Iii �U 2i� s Page of Facility Address- � �� • � City: Inspect' mDte• FA#: V L [r� PR#:� Pro ram Element:g�3: Tank/Container Inforiaiation 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 t ype. Tank(2820) ❑ Containers (2821) #of Containers: TAM D 6J`��S (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 13 ie �i� L 8-T7 l Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date. 0 0 1 Tank (2820) ❑ Containers (2821) #of Containers: TA#: -a,j [ 702-'$+ _ (>250 gallons) , (>55 gallons and 450 gallons) � ,-.. ••- 2 .. Product Type: ',,e$e,'L. ¢J/L - 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) 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 ; (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: k (>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: Z 5 D gallons Total Capacity.for Site: gallons Comments: EHD spector: Reviewed Date: Entered Date: By Initial: - By Initial. dQ� EHD 28-01 1 u v 01/16/08