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SAN JOAQUIN COUNTY ~NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 "000 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: C / T o` T �� Page of Facility Address: City: Imp ion Dat 23 LCI✓ v,fd -D 2 1 V FA#: PR#: Program Elemen 00 j 1 4 D z 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 (2820) ❑ Containers (2821) #of Containers: TA (>250 gallons) (>55 gallons and Q50 gallons) 1 Product Type: Total Capacity: /OD & 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) 2 Product Type: Total Capacity: gallons (per tank or emulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>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<250 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: gallons Comments: 3,4 ale K4 r�r EHD Insp/��o r. Reviewed Date: Entered Date: W By Initial: 't,,�' �i_r�� By Initial ERD28-01 01/16/08