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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME. 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: #,q G'40, y Sr-ir vrc Page—L—of Facility Address: City: Inspect' n Vo /S 9 2/ S• i�w6y 13 Z-vo T �c FA#: PR#: Program Ele ent: os,/J-79,? Z S Z Tank/Container Information Complete f r 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#: (>250 gallons) (>55 gallons and<250 gallons)) — 1 Product Type: Total Capacity: gallons (p or cumulative for containers by product type)WInstall Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: /951 1z 60 (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: 1 0 () L9 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) 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: O gallons Total Capacity for Site: // O O D gallons Comments: EHD Inspector: Reviewed Da Entered Date: By Initial: 'LL By Initial: EHD 28-01 01/16/08