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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN 600 East Main Street, Stockton, CA 95202-3u_. Telephone: (209) 468-3420 Fax: (209) 468-3433 Weh: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: rA �tqtvo ` W Page of l lr Facility Address: : City: / G ' i Inspect* p ate: "7 FA #:r ©o © PR #: PI / �, 6 Progra Element: -)-- YTank/Container UY Z g5 Tank/ContainerInformation Complete for all sites with cumulative aboveground storage of petroleum ;2:1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) f Coneys: 1 ` 1 (>250 gallons) (>55 gallons and Ilons) r 7ype: Total Capacity: : 0*11 Install Da (per tank or cumulative for containy product type) 2 O'T', nk (2820) ❑ Containers (2821) #of Contai4e ;� #: (Q g (>250 gallons) (>55 gallons and <250 gall ) ' o e: T fl Total Capacity: / 30 de) gallo I(per tank or umulative for containers b sdu e) 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#: 4 (>250 gallons) (>55 gallons and <250 gallons) 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 uct type) Total Capacity this Page: 0 gallons Total Capacity for Site: d tl gallons Comments: tog 3 3 Cp J b Yp � �s J'A - 17 )( EHD Inspector: Reviewed Date: / By Initial: Entered Date: By Initial -7Z fjOS--_ EHD 28-01 01/16/08