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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEI 600 East Main Street, Stockton,CA 95202-3U/-y Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / �, SK lr�A0 �h/ 0 Page J of_ Facility Address: _ City: Inspe tion ate: g Z Y-2, R- V6,61l As' Avg ItiAN7-F 1q 77Z-IV3 FA#: PR#: Program lement: 000012-91 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. ank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) +, 1 Product Type: Total Capacity: Z01 010 O gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9�:f—Lf w 2 V�- (>250 gallons) (>55 gallons and<250 gallons) 2 2.000 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: V Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) ' 3 Product Type: azaop Total Capacity: Z 0U01 gallons (per tank or cumulative for containers by product type) Install Date: (Tank (2820) ❑ Containers (2821) #of Containers: TA#: X51 L2o`��5 (>250 gallons) (>55 gallons and<250 gallons) i 4 Product Type: 0 Total Capacity: 2--OOd gallons (per tank or cumulative for containers by l Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: � (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: "4"00 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z 6 gallons FTotal Capacity for Site: Z ZSR gallons Comments: lr!✓ly 0,1& MAov S EHD Inspector: Reviewed 1 Date: tJ Entered Date: CBy Initial: (x.12' 0 By in EHD 28-01 01/16/08