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SAN JOAQUIN COUNTY / ENVIRONMENTAL HEALTH DEPARTMENT ( -JO East Main Street, Stockton, CA 95202-302. _ Telephone: -(209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: % (J Ci/� L �//3 Page of Facility Address: 4VCity: s . T fort LaDI Ins ect' n Da : � 0 FA #: rK #: Pro am Element: s 3 2 ' 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. D"T'ank (2820) ❑ Containers (2821) #of Containers: TA#: 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: 0 / L, Total Capacity: 2 4 d a gallons (per tank or cumulative for containers by product type) Install Date: LY1 ank (2820) ❑ Containers (2821) #of Containers: TA#: QS f 91y 2 (>250 gallons) (>55 gallons and <250 gallons) Product Type: p Total Capacity: ?a 013 gallons (per tank or cumulative for containers by product type) Install Date: ID-1ank (2820) ❑ Containers (2821) #of Containers: TA#: Qty / (Qsg 7 3 (>250 gallons) (>55 gallons and <250 gallons) r,� o� d Product Type: B < Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) EU -C ontainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and <250 gallons) 4 // U Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for by product type) ❑ Tank (2820) cocontainers L9 -Containers (2821) #of Containers: TAM 5 (>250 gallons) (>55 gallons and <250 gallons) � Product Type: Total Capacity: 5 gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 2 gallons Total Capacity for Site: V 3 lgallons Comments: EHD Inspector: /�_ Reviewed By Initial: Date: w f�;� L ;. i t�°� Entered Dat ,w By Initial: a V EHD 28-01 01/16/08