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SAN JOAQUIN COUNTY T)ENVIRONMENTAL HEALTH DEPARTMENT, t 1400 East Main Street, Stockton,CA 95202-3029` Telephone:(209)468-3420 Pax:(209)468=3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: CJ Ty F T� Gl�T�t '' �AA7 Page of L _ Facility Addre; City: ?r faspectioa Date: 6.6,4 9.�.. s 1 RA c IVp T/�A Gy �S3 � . n g� FA#: PR#: Program E e t` Z Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container Oroduct type. Tank(2820) ❑ Containers (2821) #of Containers:' TA#: (>250 gallons) (>55 gallons and 450 gallons) I Product Type: Total Capacity: -2/7, d (I gallons (per g Install Date: (p tank or cumulative for containers by product type) ❑ Tank2820 { ) ElContainers (2821) #of Containers:- TA#: r 2 (>250 gallons) (>55 gallons and<250 gallons) r. Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers:"4< TAM (>250 gallons) (>55 gallons and 450 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install bate: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and 450 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type)- Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) - S Product Type: Total Capacity: gallons (per tank or cumulative for containers byproduct type) Install Date: Total Capacity this Pager o- O gallons Total Capacity for Site: 66 gallons Comments: } k i EHD Inspector: V L Reviewed Date: Entered Date: By Initial: i v, il,.I Ot By InitiaL B(l EHD 28-01 01/16/08 A I