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_ SAN JOAQUIN COUNTY • ENYIRONMENTALHEALTH DEPARTMEN• 00 East Main Street,Stockton,CA 95202-302 Telephone.(209)468-3420 Fax.(209)468-3433 Web.www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: C,9-1-79,6 7:- / O Page of Fan w •�_ pty Inspectlo SDa . 0 E •i O PAN: / / 2 / / PR � ProgramE re± Tank/Container Information n4 �wV([ 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 Tank(2820) ❑ Containers (2821) #of Containers: TA#: (> gallons) (>55 gallons and 250 gallons) 1 Product Type: Total Capacity: 10 o 0 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) 2 Product Type: _ Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: _ ❑ Tank(2820) ❑ Containers (2821) #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 (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by producttype) Install Date: Total Capacity this Pagc: gallons Total Capacity for Site: gallons Comments: EHD Inspector- ReviBy Initial: Dat (}e:1p J) By Entered Date: I! q EHD 2MI 01/16/08