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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> W East Main Street,Stockton,CA 95202-3029 %W <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> ABOVEGROUND PETROnnLEUM STORAGE PROGRAM SURVEY 7FORM <br /> Facility Name: C W 5 C A r y/` b EE —T Page L— Of <br /> Facility Address: city:! City: Inspeclioo Date: <br /> FA#: PR#: Program Element: <br /> I o5 a <br /> Tank/Container Information <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 <br /> Tank(2820) ❑'Containers(2821) #of Containers: TA#: 6teg I <br /> (>250 gallons) (>55 gallons and<250 gallons) L <br /> 1 Product Type: Q 1 <br /> Total Capacity: .5 0 V gallons Mall Date: <br /> (per tank or cumulative for containers by product type) <br /> "T (2820) ❑ Containers (2821) #of Containers: TAM /Q rZ <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 2 Product Type: <br /> Total Capacity: �0 0 gallons <br /> (pa tank or cumulative for containers by product type) Install Date: - <br /> Tank(2820) ❑ Containers (2821) #oflQontainers: TA#: 19, 1P( Zf 3 <br /> (>250 gallons) (>55 gallons and<250 gallons) \ <br /> 3 Product.Type: 0 <br /> Total Capacity: / ell gallons Install Dai <br /> a <br /> (por cumulative for containers by product type) <br /> Tank (2820) ❑ Containers (2821) #of Containers: TA#: �`J [2 06-6(>250 gallons) (>55 gallons and<250 gallons) <br /> !� <br /> 4 Product Type: <br /> Total Capacity: � 6gallons <br /> (per tank or cumulative for containers by product type) Install Date' <br /> In Tank(2820) II/Containers (282 1) #of Containers: TA rj <br /> (>250 gallons) (>55 gallons and<250 gallons) <br /> 5 Product Type: I _ <br /> Total Capacity: Z0 gallons <br /> (per tank or cumulative for containers by product type) Install Date' <br /> Total Capacity this Page: (� gallons Total Capacity for Site: gallons <br /> Comments: <br /> 3� <br /> i <br /> b <br /> EHD Inspector: Reviewed Date: Entered Date: <br /> By Initial: By Initial: C,Y O <br /> EHD 28-01 t� <br /> 01/16/08 <br />