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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN" 600 East Main Street, Stockton, CA 95202-30-y Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: .;� Page / of D Facility Add res • 20 5• 5-rbrxrow City: .4 /?/OA/ Inspe ion Da S �%g FA #: PR #: 05-a�o5-0 Program Element: 72-- Tank/Container Information Tank/Container 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. IP/Tank(2820) ❑ Containers (2821) #of Containers: TA#: 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: /2000 gallons Install Date: (per tank or cumulative for containers by product type) [M/Tank(2820) ❑ Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type:sT� `RZ7 O Total Capacity: 2?S gallons Install Date. (per tank or cumulative for containers by product type) IP/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: d Total Capacity: 27 �_ gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) containers (2821) #of Containers: TA#: a rj 1 4P 4 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: / / O gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) I ✓J Containers (282 1) #of Containers: ,S TA#: 196j 1 Ze.3 f� 0 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: 61 L Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: / Z gallons FTotal Capacity for Site: 2 gallons Comments: EHD Inspector: Reviewed Date: By Initial: Wl� 1,,)0.01 Entered Date: By Initial: �'/L�/p a/ EHD 28-01 01/16/08