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r 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: 5 -j-Td A Page _) of 2� w L' , _."'-A/0 Facility Address: G saw 4/ ty: Ile '- S �/ Inspection Date - o FA #: A4,f-6 PIR #: 91 & Program le ent: 2831 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (282 1) #of Containers: TA#: 0517 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: J�1_�.� TF O � Total Capacity: 7.• O gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: 106):7 !yDq ' 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: i'1 Total Capacity: '2. '�O gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) .,i Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: T A 951 % 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: M Q T bfiL C21 (l Total Capacity: 'L 1 0 gallons Install Date: (per tank or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#:ems;1� 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: /%�f p/�� Total Capacity: ZS -d gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: Q gallons Fo tal Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date:./ By Initial: 1 ^,� kQ• �I�QU Entered Datio By Initial: 3 EHD 28-01 01/16/08