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SAN JOAQUIN COUNTY • V 0ENYIRONMENTAL HEALTH DEPARTMEN 600 East Main Street,Stockton,CA 95202-30 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: - !/ Ir ! Z— Gf�A/ (J �= d �L �/ Page— C) of L. Facility Address: City: Inspectio Date: a.P FA#: PR#: Program Element: Tank/Container Information Complete for all sites with cum lative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. C Tete one box for each tank or each cumulative container product type. Q (2820) Containers (2821) #of Containers: _ TA#: /le L 7 I 25 gallons) (>55 gallons and<250 gallons) 1 Product Type: ^/-j Al)' Total Capacity: 3 N9 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) 2 Product Type: Total Capacity: 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<L50 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: gallons 'total Capacity for Site: Z g z D gallons Comments: EHD Inspector: Reviewed7n,ate: /' Entered Date: By Initial: S (s 1c By Initial: EHD 28-01 01/16/08