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SAN JOAQUIN COUNTY P-NVIRONMENTAL HEALTH DEPARTMEI 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: 4 _ � C 0 1�-' Page of Facility Address: City: Inspection Date: FA#: PR#:7- 1 Program Element: 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. ❑ Tank (2820) CV/Containers (2821) #of Containers: TA#: f Q (>250 gallons) (>55 gallons and<250 gallons) ✓T_ 1 i L Total Capacity: -51$ gallons Product Type: D (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� D / l In Total Capacity. �� gallons —�— �r (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) eContainers (282 1) #of Containers: ,/ TA#: 3 (>250 gallons) (>55 gallons and<250 gallons) _1 � Ota Total Capacity: s-S gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) O'Containers (2821) #of Containers: TA#: P,,e f�rq 'j17 (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: 1-V,4 >/' j2 Total Capacity: �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) 5 Product Type: Total Capacity: ,�OD gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD InspectReviewed Date: --] Entered Date: L By Initial: By Initial: b EHD 28-01 01/16/08