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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.sigov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: /% C.11, z v G -5-,/C- Facility Page of Add s: it : Inspection Ye: /o o � FA#: PR#: Program cement: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product ElTank(2820) 9/ Containers(2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) I Product Type: 1M o l O� O/ Total Capacity: __ l gallons Install Date: (per lank or cumulative for conte era by prod!t type) - - - - 0-fank(2820) ❑ Containers(2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: 2 5 D gallons Install Date: (per tank or cumulative for containers by product type) ank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and Q50 gallons) l 3 Product Type: /d/,� Total Capacity: ZCle71 gallons Date: (per tank or cumulative for containers by product type) Install❑ Tank(2820) ❑ Containers (282 1) #of Containers: TAM (>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 (282 1) #of Containers: TAM (>250 gallons) (>55 gallons and<50 gallons) - 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: / ; gallons 'fot:d Capacity for Site: 6 gallons Comments: C 32-o 61Ii/ EHD Inspector: Reviewed Date: Entered Date: e By Initial: �� lO,.0-� By Initial: ' DZ EHD 28-01 0l/16/08