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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 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: � I ff -- 1 �e 1 ct' & r Ce�SOrveJ S a'i Page of� Facility Address: City: Inspect* n Date: / 2o IC/' t� was` Gi r . s L lG��v 2 Z c - o FA#: PR#: Program Element: l2 ( 0 o612 7 77 _'�5 283 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. Tank(2820) ❑ Containers (2821) #of Containers: TA# (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: (ti A p'L "j/L Total Capacity: 2 L L13 S 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) 2 Product Type: j $Y—L'G n µb�"&r 01'L Total Capacity: � gallons Install Date: (per tank or cumulative for conta ers by product type) X Tank(2820) ❑ Containers (282 1) #of Containers: (>250 gallons) (>55 gallons and<250 gallons) + ' 3 Product Type: !�'� Total Capacity: c!) gallons Install Date: (per tank or cumulative fornt coainers by product type) X Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 /� Product Type: �9 rq..�t�� Total Capacity: (� gallons Install Date: (per tank or cumulative for co tamers by product type) ❑ 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: � gallons Total Capacity for Site: S ( gallons Comments: r 6L. &,() i P- , ax& ^� EHD ector: ! Reviewed Date Entered Date: By Initial: q� O� By Initial: EHD 28-01 01/16/08