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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: n�bV // I �I �l1N` Tr. t� Page ( of �. Facility Address City:�\ \ �V N I,N�(�Cl'�J} Inspection Date: FA #: � � � PR #: Program Element: 28 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z 1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) 76 -Containers (2821) #of Containers: `V TA#: j�D66'J- 1 Total Capacity: gallons Product Type: of (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: �_ TA#: 2 Total Capacity: gallons Product Type: t4 (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: , TA#: Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: 4 Product Type: al Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: 4 - -10 ❑ Tank (2820) fContainers (2821) #of Containers: l TA#: 5 Total Capacity: gallons Product Type: ✓ o • � (per tank or cumulative for containers by product type) Install Date: — Total Capacity this Page: j gallons Total Capacity for Site: g U ;allons Comments: EHD Inspector: - Reviewed n 1. Date: Q By Initial: eu " U l �3 I'nterc I Date: B Initial b�--/) --:;, *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 09/12/08