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SAN JOAQUIN COUNTY E00NVIRONMENTAL HEALTH DEPARTM East Main Street, Stockton,CA 9520210 Telephone:(209)468-3420 Fax:(209)468-3433 Weh:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Q Page / of f Facility Address: City: Inspect'on ate: S7 . NW-1 " 17-T I ,/OF FA#: PR#• Program Element: 00011nO 5/F ?p Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1320 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#: 6-j Le&,X_�1 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: —D/� 5,-cL. Total Capacity: 1'2-0 o o 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: Total Capacity: 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) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and X250 gallons) 4 Product Type: Total Capacity: 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) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: / 2. d gallons Total Capacity for Site: gallons Comments J ' J EHD Inspector. Reviewed Date: Entered Date: C' 03' By Initial: 1-I'D By Initial EHD 28-01 01/16/08