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ti SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMEI East Main Street, Stockton,CA 95202-3025 Telephone:( U9)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: AlfR✓ JAI, 14 SJe l—/a/VQ Page L of Facility Address: City: Inspection Date: 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. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: -7 (>250 gallons) (>55 gallons and<250 gallons) — 1 / Product Type: Total Capacity: C �JO gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) P Containers (2821) #of Containers: �TA4i 4 02� (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: f z � 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 product type) Install Date: Total Capacity this Page: Z gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed ` Date: h Entered Date: / By Initial: �1N �'\1. o� By InitialET v �4 EHD 28-01 01/16/08