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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN' 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STO GE PROGRAM SURVEY FORM Facility Name: C-A Ci TR A NS Page / of 2-- Facility AddressZ 0 Ar: ;1-1,e fq � Inspe /Date T FA#: / PR#: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Tank(2820) ❑ Containers (2821) #of Containers: T #: D51 7 Dg (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: � Total Capacity: 2—o OB gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) IR Containers (282 1) #of Containers: TA#: f 6-1-76 S l� (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: -�!- Q gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) P Containers (2821) #of Containers: TA#: 70R0 (>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) W-6ontainers (2821) #of Containers: r TA#: i9 l 70 (>250 gallons) (>55 gallons and<250 gallons) l 4 - Product Type: (�.-ESR, Total Capacity: S,� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) MContainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: �j�./�� d� Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2- 3 4, gallons Total Capacity for Site: Z gallons Comments: EHD Inspector: Reviewed Date: ✓ Entered Date: / By Initial: h� F•Lo' By Initial: � a D EHD 28-01 01/16/08