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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 600 East Main Street, Stockton, CA 95202-302y Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: zo /v 1 I P �B� % v Ci T Agn/ &oma Page of Facility Address: ity: o s .�� s•I L k? G Inspec . n te: o �f - FA #: C)GU 5 �" PR #: IF 51ar/ 1 Program lement: 2., Y 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#: 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: �✓ , Total Capacity: 2, O b V 0 gallons 1 (per ynk or s (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and <250 gallons) �- Product Type: �i odd � Total Capacity: -2,,,,5O-P 0 gallons Install Date: (p 1) #of Containers: TA#: 3 (>250 gallons) (>55 gallons and <250 gallons) ^ Product Type: ,I, 01 `0/2 p Total Capacity: gallons (per tank or cumulative for conInstall Date: tainers by product type) Tank (2820) ❑ Containers (2821) #of Co ers: TA#: 66j- le /00 4 (>250 gallons) (>55 gallons and <250 gallons) ✓ Product Type: ��-(,ru iC -�- ;,'! Ol Total Capacity: &V - D ners by product type) 1. IP/Tank (2820) ❑ Containers (2821) #of Containers: TAM 5 gallons) (>55 gallons and <250 gallons) �—� Product Type: a--�y-�-�— Y?v�� (�j�lJ —1 (1) r Total Capacity: - 0 gallons - t-1� ,�, (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 000 gallons I Total Capacity for Site: gallons Co tints: Uaf— U''o TA 7, 9 3S �G �✓ /�I G F EHD inspector: Reviewed �� D Date: L – By Initial: ilial: TV lovrlb EHD 28-01 01/16/08 VO ko.S.ko