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SAN JOAQUIN COUNTY ;'NVIRON1b1ENTAL HEALTH DEPARTMENT OO East Main Street, Stockton,CA 95202-30 - Telephone:(209)468-3420 Fare:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: C lil U G k ry o Page. of L � Facility Address: City: Inspect! Dat 1i 6v i FA#: -Pli#: � D O Program Element: tC 05agtoI z4 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Com fete one box for each tank or each cumulative container roduct e. ❑ Tank(2820) Containers (2821) #of Containers: Z TA#: (>250 gallons) ' (>55 gallons and<250 gallons) //' Total Capacity: J a gallons Product Type: L (per ate: //tank or cumulative for containers by product type) Install D - P/Tank(2820) - ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) �-- 2 Product Type:. ,S f� Total Capacity: S b gallons (per tank or cumulative for containers by product type) Install Date: Off"Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q.50 gallons) . 3 Product Type: a/ Total Capacity: 4'00 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: ,gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers'(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons IrlstalI Date: (per tank or cumulative for containers by product type) Total Capacity this Page: gallons Total Capacity for Site: �� gallons 3 �N EHD Inspector: Reviewed Date- Entered Date: By Initial: l �'� By Initial: C 8 1 EHD2MI 01/16/08