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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 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: 14L-r d Page I of Facility Address: City: Inspec�Ion Da ! SL C. 7C/" k4r/ TCC g�Z�' FA#: PR#: Program Element: �3 B� 05172 S-1-3 2 Tank/Container Information Complet for all sites with cuk#ative aboveground storage of petroleum >1320 gallons in tanks and containers over 55 gallons. C Tete one box for each tank or each cumulative container product type. Tank (2820) ontainers (2821) #of Containers: TA#: 176 17 / I q (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: g D gallons Install Date: (per or cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #of Containers: TA#: L96-1 f o2 O (>250 gallons) (>55 gallons and<250 gallons) 2 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) 3 Product Type: O Total Capacity: gallons kWz (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: 71,V02 (>250 gallons) (>55 gallons and<250 gallons) r 4 Product Type: Total Capacity: `4 a 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) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: 9 0 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: J By Initial: By Initial: /J EHD 28-01 O 01/16/08