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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 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: - CZ 14 u SQL, � Page Facility Address: City: Ins ectlon Date:o f /G4Z FA#: PR#: Prolem 2ra;Eent: 3 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container Droduct tviDe. Tank (2820) ❑ Containers (2821) #of Containers: TA#: T6• a I 1 Total Capacity: U gallons Product Type: r! e ¢p V 7 7, V (per tank or cumulative fort ntainers by protluct type) Install Date: _y/J(,j IlL, ,_1\ Tank (2820) ❑ Containers (2821) #of Containers: TA#: �'Jq,c, �_ 5` 2 Total Capacity: gallons Type: -2�L (per tank or cumulative for ar tw1l. duct type) Install Date: K-n,# J Tank (2820) ❑ Containers (2821) #of Containers: 3 Total Capacity: D/ll) gallons Product Type: $ (pertank or cumulative for for containers by type) Install Date: 4 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 q — Total Capacity: _ I I trs Product Type: gallons 1'/ (per tank or cumulative for containers by product type) Install Date: U Nkyyi- J Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: I e 1)bb gallons Product Type: je AIo (per tank or cumulative for containers by product type) Install Date: �i�-�. `� Total Capacity this Page: 00 gallons Total Capacity for Site: Comments: 25� gauons EHD I e Reviewed Jv 3 Date: Entered Date: By Initial: n-OM By Initial: bovegrou d storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. / **Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM