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SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMENT 6.t00 East Main Street,Stockton,CA 95202-3020—d Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: C 7- V G PjPage of Facility Address: City. laspec'on Da I S-� W A G $ zr o� FA#: PR#: Pro ram Element: 94� a`s' 1 05o24333 1 Z Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complgft one box for each tank or each cumulative container product type. ❑ Tank(2820) ontainers(2821) #of Containers: /� TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 0/ l/ Total Capacity: ' "Z-4L & gallons Install Date: (pa tank or cumulative for containers by product type) — Tank(2820) El Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and<250 gallons) Product Type: / S?/ E 0/ i Total Capacity: SOh gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) Containers(2821) #of Containers: .S TAM (>250 gallons) (>55 gallons and<250 gallons) $' 3 Product Type: , L f//��.LF _ -- Total Capacity: �7 gallons Install Date: (pa tank or cumulative for containers by product type) - -- ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: '.?- Total .?-Total Capacity: gallons 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) 5 Product Type: Total Capacity: gallons Install Date: (pa tank or cumulative for containers by product type) Total Capacity this Page: gallons Total Capacity for Site: pl gallons Comments: p4Aa2 Ar v TSS Of O� TitJ�✓/C o - I/✓ Lo/✓T.4n E,✓T F � EHD inspector: / Reviewed Date: ,/ Entered Date: r By Initial: vvqi c6,Lb-U By Initial: tl EHD 28-01 01/16/08