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SAN JOAQUIN COUNTY i ENVIRONMENTAL HEALTH DEPARTME. 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: 5�-64i 0 FVtj CoSaXj Co . rA,&/ , Page of Facility AdV dddress: o OC. vi S , City: // L if / /� Inspect on Date: g FA #: E S2 PR #: I 'P 05a-77 Program E e ent: 783t Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum _> 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. Tank (2820) ElContainers (2821) #of Containers: TA#: 1 (1250 gallons) (>55 gallons and <250 gallons) Product Type: / G Set Total Capacity: C30 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) Containers (2821) #of Containers: TA#: 2 250 gallons) (>55 gallons and <250 gallons) Product Type: PG+ rb 1 Rte ' 0/ L A -06U(/ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 'V Containers (2821) #of Containers: �_ TA#: p 57 3 (1250 gallons) (155 gallons and <250 gallons) Total Capacity: Z 6 Product Type: 1QQ � � � P�(fi,� =!;c 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) 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 Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: 3 Q gallons Total Capacity for Site: �� gallons Comments: oft, I rn b �. 4-rzmuul� hu EHD ector: Reviewed By Initial: Date: i� 'L 4 ((� Entered By Initial: Date: EHD 28-01 01/16/08