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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT A 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 ! 7- ✓ OF %? P C (30YD 5-E2VIC-F C6 IV rile Page of y_ Facility dress: City: �Z6 s �o T �y e 953 91 Inspection Date: , ilap FA #: • _ _ PR #: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z 1320 gallons in tanks nd containers over 55 gallons. Complete one box for each tank or each cumulative container product typ . Tank (2820) ❑ Containers (2821) #of Containers: TA#: �57�u 77t9 1 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Zt/'Of" Total Capacity: Od gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) riezcntainers (2821) #of Containers: TA#: 5-1 2 (>250 gallons) (>55 gallons and <250 gallons) Product Tyke: D Total Capacity: '//0 gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) Containers (2821) #of Containers: TA#: li7 / 7D7,,2 3 (>250 gallons) (>55 gallons and <250 gallons) Product Type:,�,�� < G Total Capacity: �-� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) E9'Containers (2821) #of Containers: �, TA#: 71f Z7 4 (>250 gallons) (>55 gallons and <250 gallons) Total -Capacity: ? v Product Type: G � gallons Install Date: (per nk or cumulative for containers by product type) Tank (2820) ❑ Containers (2821) #of Containers: TA#:�, fL j %�'y 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: zao�') Total Capacity: O 004* gallons Install Date: (per tank or cumulative for c tainers by product type) Total Capacity this Page: l /0,70 gallons p FTotal Capacity for Site: Z Z 2 0 gallons Comments: EHD Inspector: c/ Reviewed Date: By Initial: W"1/l,'k Entered Date: By Initial: EHD 28-01 01/16/08