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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMET A0 East Main Street, Stockton,CA 95202-31,_ - Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: l �� / ' / i� tl 1 I r Page / of Facility Address: City: / Inspectio Date•, 7-/ L �� iT Lr Ai� Sr�� FA#: PR#: ! Program Element: i f Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z 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#: Q,�1'7��7 (>250 gallons) (>55 gallons and<250 gallons) —n�' - r 1 /✓�[�a�" Total Capacity: / 2- 0 6 O gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) LkContainers (2821) #of Containers: TA#: dJ� (>250 gallons) (>55 gallons and<250 gallons) �� n 2 / (t S Product Type: G Total Capacity: r 1/ 0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) containers (2821) #of Containers: 1 TA#: (>250 gallons) (>55 gallons and Q50 gallons) �` / O 3 t Product Type: Gv T L� Total Capacity: 5S gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: STA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: -ZZ 0 gallons (per tank or cumulative for containers by product type) Install Date: NOOTank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: 016- Total Capacity: � a fl gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z gallons Total Capacity for Site: gallons Comments: VT 1914511 EHD Inspector: viewed Date: �/ Entered Date: By Initial: U.rtJ -j,l-Di b By Initial: `EHD 2841 01/16/08