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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 STORAGE PROGRAM SURVEY FORM Facility Name: C O CL C T Page of Facility Address: City: Inspec ion ate: 1 6 5 S. L rvco �- 8 °I FA#: PR#: Progi m Element: ba 2 1 ar5';?L3z5- 1Z g� 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: 3 TA#: a o (>250 gallons) (>55 gallons and<250 gallons) 1 6 Product Type: Total Capacity: ` S gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ontainers (2821) #of Containers: ( Tk#: _ (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: _7 _gallons (per tank or cumulative fo --.crs by product type) Install Date: C9/1'a k(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: L 6 gallons (per tank or cumulative for containers by product type) Install Date: EI/Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: 440 D gallons (per tank or cumulative for containers by product type) Install Date: Lr"Tank (2820) ❑ Containers (2821) #of Containers: TA#: R6_ Mpg (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: f t� Total Capacity: 6f gallons , (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: L5 gallons Total Capacity for S 2,0 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: � By Init' 1/ EHD 28-01 01/16/08