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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN' 600 East Main Street, Stockton, CA 95202-302y Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: )vV C (., ft30.js Page 7,— of Facility Address: City: Inspop Date P 2 FA #: PR #: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum > 1320 gallons in tanks and containers over 55 gallons. Co tete one box for each tank or each cumulative container product type. ❑ Tank (2820) &kontainers (2821) #of Containers: I TA#: Atm/0n73 I (>250 gallons) (>55 gallons and <250 gallons) 1 Product Type: WAfTr ,4 iV?n 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) 2 Product Type: Total Capacity: 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) 3 Product Type: Total Capacity: 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) 4 Product Type: Total Capacity: 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: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallonsTotal Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: rp By Initial: By Initial: /a/DE "L' '—� V ,-'J EHD 28-01 01/16/08