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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3 f20 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: g /e 0Z-/�Uf'i" Pae of 2 Facility Address: City: Inspe do Date: /S/ --7- Gi/�/S'S �/ l �sG�1WrV C -f'T FA#: ® ® V 9 f 6 7PR Pram Element: 5!6 z 7-3 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: TA#: te (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: '�—A S Total Capacity: / 9 IS gallons (per tank or cumulative for c ntainers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: / Gd gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: le g (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: S(/�/��,F �y/j S, S Total Capacity: / �f y 0 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) 4 Product Type: (1641rr�� Total Capacity: /L/50'C> gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: l Z� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: . Entered Date: EHD Inspector: Reviewed Date: By Initial: w(� •LA By Initial: ? D EHD 28-01 01/16/08