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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN/i 600 East Main Street, Stockton,CA 95202-3%,- Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Ct-0WrK� Page of Facility Address: City: Inspectia}r�D�t ,v jr, T —r /VVI a FA#: �OO � nR � � Program I�jt/ Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks and containers er 55 gallons. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: / D b gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) 'Containers (2821) #of Containers: T #: a lQ 7 g (>250 gallons) (>55 gallons and<250 gallons) ^. 2 Product Type: Total Capacity: / 'Zy gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) 0,<ontainers (2821) #of Cont ' ers: 2,, TA#: 4 51& Z91a (>250 gallons) (>55 gallons and<250 gallons) 3 Produ ype: 0 / Total Capacity: F O� gallons (per tank or cumulative for containers by product type) Inst I"Date: ❑ Tank(2820) D ontainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: S, gallon (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers 821) #of Containers: TAM (>250 gallons) (>55 gallons and 0 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: / gallons Comments: All A = -1,e. C EHD ector: Reviewed Date: Entered D e: r By Initial: �� 7�' By Initial: `� Q / 1 D28-01 01/16/08