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SAN JOAQUIN COUNTY D �D ENVIRONMENTAL HEALTH DEPARTMEN'1.1"1W 600 East Main Street,Stockton,CA 95202-3029 <(,� Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / f A, � /1 c /f,U v (� Page of .? Facility Address: /l•J• (' O Y` CI Inspect n Date: l Z `7 UB FA#: t ,l -7 1 PR#: Prog 2 2`y> 3m Element: n' 3 `� _1 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Tank(282 ) ❑ Containers (2821) #of Containers: TA#: (>250 ga0ons) (>55 gallons and Q50 gallons) Product Type: M04/- D%L /E W-�� apace y. U gallons (per tank or cumulative for containers by product type) Install Date: x Tank(2820) ❑ Containers (2821) #of Containers: TA#: 12— 19 6T1 le.7,W (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: b i eS'e� - >"tXl. Aj0 2— Total Capacity: l 0 � D LSI 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) 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<250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (282 1) #of Containers: TAM (>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: I o c) gallons Total Capacity for Site: 2 Sl7 gallons Comments: EHD tor: ✓ Reviewed al ' EnteredDao- By Initial: �� By Initial: t EHD 28-01 01/16/08