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t It SAN 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 fiN&P Page of Facility Address: City: _ 1. Gyri r Lo L PJ a1 Inspection�'}Da� / V -5—G_ FA #:PR 6 M -7 3,-2- Program Element: -Z. 3 z1511 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. CyTank (2820) El Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: / 0 D d gallons (per tank or cumulative for containers by product type) Install Date: ❑ #of Containers: TA#:r/D�7�1 Tank (2820) LI Containers (2821) 2 Total Capacity: Z�C� gallons Product Type: S d / (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 2/containers (2821) #of Containers: TA#: 3 r Product Type: ,y1c)n Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ED'/Containers (2821) #of Containers: i TA#: c3 4� Product Type: % % Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) C�Gontainers (2821) #of Containers: �_ TA#: d5�� 5Product Type: _ _ O Z— L4La /^ Total Capacity: 5� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page. 5 Cgallonsl Total Capacity for Site: j �� gallons Comments: EHD Inspector:�o 1 ' ' Reviewed 5- A, Date: By Initial: VIAIv U �j�' Entered Date: By Initial: I *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum.- "Container etroleum-**Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08