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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEP0 <br /> 600 East Main Street,Stockton,CA 95202-30 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web.www.sjgov.org/ehd <br /> ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br /> Facility Name: <br /> C K / d�Z A Page of <br /> Facility Address: v City: _ / Inspe7,79 <br /> ti n Date: <br /> �i d ^ Z 6 B <br /> FA#: pvvc PR#. S✓ ` ' r '? Pro t- 8 Element: <br /> Tank/Container Information /f <br /> Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. <br /> Complete one box for each tank or each cumulative container product type. <br /> Tank(2820) ❑ Containers (2821) #of Containers: A#: �/ ('c <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> I D Product Type: ] D <br /> Total Capacity: O 6 Q gallons Install Date: <br /> (per or cumulative for containers by product type) <br /> Tank (2820) ❑ Containers(2821) #of Containers: TAM r5i LoAf I (.P <br /> (>250 gallons) (>55 gallons and<250 gallons) J <br /> 2 Product Type: 1�?t O�A�`� <br /> Total Capacity: Z0 O CIO gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> M/I' nk(2820) ❑ Containers (2821) #of Containers: Le <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 3 Product Type: 1"L(pa <br /> Total Capacity: 7-0 C2 U 0 gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> �fank(2820) ❑ Containers (2821) #of Containers: TA#: Ir q- <br /> 4 <br /> gallons) (>55 gallons and<250 gallons) <br /> 4 Product Type: <br /> Total Capacity: ZD 0 C O gallons Install Date: <br /> (per tank or cumulative for containers by product type) <br /> ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: <br /> (>250 gallons) (>55 gallons and<50 gallons) <br /> $ Product Type: <br /> Total Capacity: gallons Install Date: <br /> (per tank or cumulative for containers b duct type) <br /> Total Capacity this Page: gallons Total Capacity for Site: 6 O gallons <br /> Comments: <br /> EHD lnspector: Reviewed Date: Entered Date: <br /> / _ + By Initial: ) 1 .4v.Qg By Initial: <br /> EHD 28-01 <br /> 01/16/08 <br />