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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEP East Main Street, Stockton,CA 95202-30._ Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / �CllJf� ✓A p Page of Facility Address: City: Inspect' n D t I] �DD 1 1tVP '1/LL Gov , 6 / Z70 8 FA#: PR#: Progr EI nt: � © d o ,63e /� �� Zg57 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#: (�llLll�b 1 (>250 gallons) (>55 gallons and<250 gallons) Product Type: Total Capacity: Z-3'0 o 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) 2 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) 3 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) 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 prod t type) Install Date: Total Capacity this Page: 2. gallons Total Capacity for Site: 2 5 b gallons Comments: d g 3 O EHD Inspector: /� _ Reviewed Date: TBy red Date: By Initial: ` , �V`1-0, nitial: Q� D EHD 28-01 01/16/08