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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 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: I A rD UJ S-{vz,1C 0 'r"Qlh . Page of Facility Address: City: Inspec 'on Date: 7 -7C O Wt NUMB O I N &TvN V-- S/?1�- � 2 2p v O FA#: PR#: Program Element: I o Z 3 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >t 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: TA#: �66-k6-tF 7q (>250 gallons) (>55 gallons and<250 gallons) n 1 Product Type: �G Total Capacity: 2 Moab gallons Install Date' (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: (29915-'76— >250 gallons) (>55 gallons and<250 gallons) 2 Product Type: At�- Total Capacity: }(,U gallons (per tank or cumulative for co tainers by product type) Install Date: X Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: j ZPO-u ]fejt/6- 2'7& Total Capacity: Ll Do gallons (per tank or cumulative for containers by product type) Install Date: %1 ❑ Tank 2820 Containers 2821 ( ) ( ) #of Containers: TA#: (>250 gallons) >55 gallons and<250 gallons) 4 Product Type: PQ4f-b (.e 0--, (., (ar) C AIJ7 Total Capacity: r), '20 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) EI Containers (2821) #of Containers: TA#: V �� Z (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons I�pInstall Date: (per tank or cumulative for containers byproduct type) Z Total Capacity this Page: gallons Total Capacity for Site: lions Comments: EHD In to . Reviewed Date: Enteredte: i4 v _ By Initial: By Initial: vl B EHD 28-01 ✓✓ �- l 01/16/08