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SAN JOAQUIN COUNTY 1'l LIf 'ENVIRONMENTAL HEALTH DEPARTMENI o00 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: C, G fl T2 p LE uAA Page-/ of Facility Address: City: Inspection Date- Z oo kf3 SSa �✓ Rr� % A �% � FA#: PR#: ProgElment: V0IbZo � P/e,a S/t `f3 :27 '32-- 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) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: ,/5 O 00 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: '/l7"� (>250 gallons) (>55 gallons and<250 gallons) � 2 Product Type: Arwicez Total apacity: 2-0 P d O gallons (per k or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: 6Y4 Total Capacity: Z D 0 d 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 (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) 5 Product Type: Total Capacity gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date Entered Date: By Initial: D� By Initial: EHD 28-01 01/16/08