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SAN JOAQUIN COUNTY 1NVIRONMENTAL HEALTH DEPARTMENT-j. East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd y ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name r /'j7/^ Page �_of c 1a. -:D or � City: nspection D te: Facility Address: srG- ps' zo b Z _ s h/L ProgramPR E err a t E FA# �(� aBlP`7o Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1320 gallons in tanks and containers over 55 gallons. Co lete one box for each tank or each cumulative container product e. I� ank(2820) - Containers (2821) #of Containers: TA#: �-r ` 250 gallons) (�55 gallons and X250 gallons) 1 Product Type: C/ C• � Total Capacity i' allons p �' � �� ,g Install Date: ' (per tank or cumulative fox ;-by product type) ❑ Tank(2820) [E Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) i 2 Product Typ .m 0—N7 1?— 0� Total Capacity: �5 gallons r (per tank or cumulative for containers by product type) Install Date' ❑ Tank(2820) -8/Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 3 r 'Product Type: 'IAZA Total Capacity: J 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) 0 Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and 450 gallons) 5 , Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 6S j gallons Total Capacity for Site: ` gallons Comments: y s EHD Inspector: Reviewed Date: Entered Date: By Initial: * O,q- By Initial: 3/1!561 EHD 28-01 01/16/08 - r