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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART 600 East Main Street, Stockton, CA 95202- 029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: i% �% / of MAI YJ h/ (/5r-&yPage Facility Address: City: r So V N : (� L v p Inspe7rZWfF FA #:©o © t, vx PR #: r / Jt /� b � Progra -: Z F 85 -Y 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#: �%,�( IV 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: 400-w°' Total Capacity: /:7 o -s -P gallons Install Date: (per tank or cumulative for containers by product type) LTJ'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0 (Q V ,!� 0 2 (>250 gallons) (>55 gallons and QSO gallons) Product Type: Total Capacity: % 30Oy gallons 2 (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 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#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by ucttype) Total Capacity this Page: 6 d U 0 gallonsl Total Capacity for Site: gallons Comments: Z o'j 334P-164-0 � .� f S TA I//S 1 ZAA-e�s 4,4 sA G -E - EHD Inspector: Reviewed Date: By Initial: 0.-' X4'0 By Entered Date - By Initial: 7 EHD 28-01 01/16/08