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SAN JOAQUIN COUNTY WNVIRONMENTAL HEALTH DEPARTME .,00 East Main Street,Stockton,CA 95202-3uz5o Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: '/ ef N-- Page of Facility Address: 1 o City: /� [nspec ion Date: 0492 , [i1604 FA#: PR#: Program Element: L9191603171U 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 (2820) El Containers (2821) #of Contain a (>250 gallons) (>55 gallons and<250 gallons I 1 f— Product Type: A 5 - Total Capacity:- G 0 gallons (per tank or cumulative fo containers by product type) Install Date: ❑ Tank (2820) CKContainers (2821) #of Containers: / TA#: Q,52jq,3!7g (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: AA DfiD r oil l Total Capacity: �LS O gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) XContainers(2821) #of Containers: TA#: B Sao 6 9 (>250 gallons) (>55 gallons and<50 gallons) 3 Product Type: r7_Z.G(L'C ®/ l Total Capacity: 3 -,--220 gallons Install Date: (per tank m cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<50 gallons) 4 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) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 0 gallons Total Capacity for Site: 4& 2 CD gallons Comments: C EHD In tor. Reviewed Date: /I/`� Entered Date: (`JJ I i By Initial: J � By Tnitiak /� EHD 28-01 01/16/08