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MSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 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: C f F 9 S /A j�vl s Page of Facility Address: L, City: d (� o Zr—^/,y 7s � Inspection Date- - 0 FA #: PR #: Program Elemeal : Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks* and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: /5) 1 glQ 1Product Total Capacity: J n 0 gallons Type: ej2� (per tank or cumulative for containers by product type) Install Date: G2" Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: Cy gallons Product Type: 4, a aZ (per tank or cumulative for containers by product type) Install Date: 7[t jl ank (2820) El Containers (2821) #of Containers: TA#: ^ I 3Product Total Capacity: r—& --o gallons Type: (per tank or cumulative for containers by product type) Install Date: ank (2820) El Containers (2821) #of Containers: TA#: 01 4 Total Capacity: r gallons Product Type:�l-P� (per tank or cumulative for containers by product type) Install Date: � ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (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: By initial: f10 Entered Date: By Initial: 02/ Q *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum` "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08