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SAN JOAQUIN COUNTY ;NVIRONMENTAL HEALTH DEPARTMEN' ` .,00 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: �. ��K Page of Facility Address: Ciel. Inspection ate: 02,1 /q .�72d,n/� L ov l10T FA#: PR#: Progra Ele ent: 3 _Z_ `� �ag f,� g 3 0 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. ER"Tank (2820) ❑ Containers (2821) #of Containers: TA# (>250 gallons) (>55 gallons and<250 gallons) n 1 Product Type: 1 1 Total Capacity: / 0 C-) -0 gallons (per tank or cumulative for containers by product type) Install Date: E Tank(2820) ❑ Containers (2821) #of Containers: TA#: IP (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: A s Total Capacity: c, gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>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<250 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: 0 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: _I Entered Dater ` By Initial: l},� By Initial: / EHD 28-01 c 01/16/08