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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEr 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 Facility Name: a U ,y Z' Pagey of 'tiJ Facility Address: City: Inspection Dat U&� ` FA#: PR#: Program E menta Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum �1320 gallons in tanks and cont�overgallons. Co Tete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (282 ners: , TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: �L$r�� d'r Total Capacity: d ' gallons �tzafib� cr -( er tank or cumulati In all Date: ja-Tank (2820) ❑ Containers (2821) #of Containers: TA#• (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: 'fL° Total Capacity: � j_) gallons 61A Install Date: (per tank or cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: T" (>250 gallons) (>55 gallons and<250 gallons) f 3 Product Type: _ l,l,�ti Total Capacity: U gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: t2;Al �S (>250 gallons) (>55 gallons and Q50 gallons) 4 Product Type:I/U,I�i�tiyit c; Total Capacity: gallons ��ii �z�{,`�v�= e-f'Rr cit flre-4 (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) $ Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: I U gallons Total Capacity for Site: P1 gallons Comments: �' f 11P EHD Inspector: Reviewed /� Date: Entered / _ Date: By initial: �� _ ` By Initial: EHD 28-01 01/16/08