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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN', 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: ^' (e `rYuc(c� 1 ]u( . Hi Page of 3 Facility Address: X100 W City: c Inspection Date: FA #: � PR #. // Program Element: -- [P 9-V 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. K] Tank (2820) ❑ Containers (2821) #of Containers: TA#: Ob 1 (>250 gallons) (>55 gallons and X250 gallons) Product Type: Diesel Fuel T Capacity: �Q� gallons Install Date: (per r cumulative for containers by product type) ISI Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) OM Product Type: I awAme -(2ine l Tot Capacity: gallons Install Date: er tan r cumulative for containers by product type) It Tank (2820) ❑ Containers (282 1) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) S�5 Product Type: YK40l' of Total Capacity: gallons per or cumulative for containers by product type) Install Date: ❑ Tank (2820) IN Containers (2821) #of Containers: 3 TA#: 4Product (>250 gallons) (>55 gallons and <250 gallons) 55- 3 Type: i e To apacity: x gallons Install Date: ,forr cumulative for containers by product type) ❑ Tank (2820) Containers (2821) #of Containers: 3 TA#:� 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Tot pacity: �s x 3 gallons Install Date: r cumulative for containers by product type) Total Capacity this Page: S gallons Total Capacity for Site: 7t,gallons Comments: EHD Inspector: Reviewed By Initial: Date: Entered Dater ) By Initial: / EHD 28-01 I 01/16/08