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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIP o00 East Main Street,Stockton,CA 95202-30ty Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Y"1 1 I! L 1L 'C v Page of Facility Address: City: Inspecti n Daty: o lir V O IJ W 1,04 6� FA#: PR#: rProgram Element: Tank/Va ainer Information Complete for all sites with cumulative aboveground stof petroleum >_1320 gallons in tanks and containers over 55 gallons. Complete one box for eachor each cumulative container product type. Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) i Product Type: Total Capacity: Svr o gallons (per tank or cumulative for containers by product type) Install Date: R-'Tank (2820) ❑ Containers (2821 #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: -�o O gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>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: G gallons Fotal Capacity for Site: Z Z-L d gallons Comments: EHD Inspector:� � / / D �f Reviewed Date: � t'� ytered Date: 6 ]l B Initial: �2 V B Initial: iY EHD 28-01 01/16/08