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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: �- J f Pagey of 07 Facility Address: City: In777)'y D l� 4.x) 1 FA #: PR #: Program El ment: �D 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. Rf"Tank (2820) ❑ Containers (2821) #of Containers: TAM 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: --P*,(-,,— , � Total Capacity: / v 0 b gallons Install Date: al.lfw at la,g mulative for containers by product type) 46 Tank (2820) ❑ Containers (2821) #of Containers: TA#: C, (>250 gallons) (>55 gallons and <250 gallons) 2 Total Capacity: F0 gallons Product Type: ( y' (,� ,�,�n= Gc iA (per tank or cumulative for containers by product type) Install Date: `6' Lank (2820) El Containers (2821) 0 #of ContA#: /�5[ ke J �3 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type: r,4 Total Capacity: gallons &jurr4� Install Date: ) c k ct cut '� (per tank or c ve for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#: �j (e 13-6— (>250 gallons) (>55 gallons and <250 gallons) 4 Total Capacity:ll'I"� gallons Product Type: y/ 11 r , f w+: cr AW, (per t k or cumulative for containers by product type) Install Date: ❑ Tank (2820) 'l�Containers (282 1) #of Containers: TA#: 19 -Ay ``j 62 (>250 gallons) (>55 gallons and <250 gallons) 5 ' �"? Product Type: (jj-}�,�1nL1,{�Z Total Capacity: gallons Install Date: �� awl k or cumulative for containers by product type) Total Capacity this Page: 27C gallons Total Capacity for Site: gallons Comments. EHD Inspector: o h 1 Reviewed By Initial: Date: Entered Date By Initial: L, EHD28-01 01/16/08 i! 1