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SAN JOAQUIN COUNTY ' ENVIRONMENTAL HEALTH DEPARTM 00 East Main Street,Stockton,CA 95202-302 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM? Facility Na % c k N ^v&6 A�D D/-1-41A 11/L.ER S Page / of Facility Address: (/J� City: [nspec' n Dat z 7 C LR k ,ok STK 60*vl�a� FA#: PR#: Program El eme t: p ©�oo3 ,� d/ 7 2- 83 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 type. Tank(2820) ❑ Containers (2821) #of Containers: �A#: /(ems (>250 gallons) (>55 gallons and Q50 gallons) 1 Total Capacity: '(00 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: IR/Tank(2820) ❑ Containers (2821) #of Containers: TA#: N,61 6P?o2/P (>250 gallons) (>55 gallons and Q50 gallons) 2 Product Type: 6—A.S _ Total Capacity: 10 Uy gallons Install Date: (per tank or cumulative for containers by product type) Tank(2820) ❑ Containers (2821) #o Containers: TA#: 51 LC7,27 (>250 gallons) (>55 gallons and Q50 gallons) / 3Product Type: 0-A S Total Capacity: 7 �D gallons (per tank or emulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) 4 Product Type: /,--A Total Capacity: Z�D gallons (per tank or cumulative for containers by product type) Install Date: IR/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 51 LP 5 (>250 gallons) (>55 gallons and Q50 gallons) yp Product T e: � O� Total Capacity: 3 Oy gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 80 0 gallons Total Capacity for Site: 6v gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: kprj v1-o By Initial: EHD 28-01 01/16/08