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SAN JOAQUIN COUNTY IRONMENTAL HEALTH DEPARTMENT 60 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: s Page of � 1, / R G l l✓ Facility Address: City: Inspecti n Da[ 6 !' o r PR#: Program�jleement: FA#: 2- / / 7 poo 3 ? 4 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 e. Tank (2820) ❑ Containers (2821) #of Containers: TA#: w-/ Sg,6 7 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 0 t 2/i Total Capacity: 10 0 0 c gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ldtiontainers (2821) #of Containers:/ TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: / Total Capacity: Ss gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ontainers (2821) #of Containers: , TA#: QQCj (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: �,� gallons (per tank or cumulative for containers by product type) Install Date: / [I Tank(2820) R-Containers (2821) #of Containers: / TA#: (>250 gallons) (>55 gallons and<250 gallons) - - 4 Product Type: Total Capacity: . /�_gallons (per tank orrcumcumunlative for can niers by product type) Install Date: Tank(2820) El Containers (2821) #of Containers: T�L#: NE (>250 gallons) (>55 gallons and<250 gallons) $ Product Type: Total Capacity: Vw gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 6 gallons Total Capacity for Site: 3 x/ gallons Continents: EHD Inspector: /) t ReviewedDate: Entered Date: O� Bylnitial: (�_�-0� By Initial: EHD 28-01 01/16/08