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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT X00 East Main Street,Stockton,CA 95202-302. Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: C ✓ T d G O N Page of Facility Address: City: Insp11-3 o Date: zzzz ��. Mak Ln/ -S-7-0 G bh b (5 8 FA#: PR#: Program EI poo 3� 49,502 8 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1320 gallons in tanks and containers over 55 gallons. Copaplete one box for each tank or each cumulative container product type. TankM20) Containers (2821) #of Containers: / TA#: (>250 gallons) (>55 gallons and<250 gallons) / 1 Product Type: ��S' �= Total Capacity: , � :5't) gallons (per tank or cumulative for containers by product type) Install Date: GJ,'Ofank (2820) ❑ Containers (2821) #of Containers: TA#: B51 CP 3 ( Y (>250 gallons) (>55 gallons and<250 gallons) / 2 � / � Product Type: � / Total Capacity: 67 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) EP`Containers (2821) #of Containers: TA#: 2951 4�11876: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: /Z e) gallons Install Date: (per tank or cumulative for containers by product type) IR/Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) p� 4 Product Type: Gds d Total Capacity: / 0 U (9 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 Fotal Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: ` By Initial: t jtj 1, 1,�� By Initial: EHD 28-01 V 01/16/08