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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT N '600 East Main Street,Stockton,CA 95202-302�I Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name• C LA g5y GRASS -rvln F Page of Facility Address; Ciecf/[o/p�//jays, �7yy� ZZ d T City: FA#: PR#: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product Le'rank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: � fj Total Capacity: /0 06 gallons (per tankorcumulative for containers by product type) Install Date: Qui;nk(2820) ❑ Containers (2821) #of Containers: TAM rj / (y g(o 2 (>250 gallons) (>55 gallons and<250 gallons) Product Type: �7Ita lu l- Total Capacity: gallons (pa tank or cumulative for containers by product type) Install Date: Ei4ank(2820) ❑ Containers(2821) #of Containers: TA#: _ (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: eYA S Total Capacity: ,�U b gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) - 4 Product Type: Total Capacity: gallons (pa 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: r gallons Total Capacity for Site: gallons Comments: 01✓ est/, EHD Inspector: /7 �1 Reviewed Date: Entered Date: I V By Initial: � 1 lt,.p By Initial: EHD 28-01 \/ 01/16/08