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4' SAN JOAQUIN COUNTY f ., sNVIRONMENTAL 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 --,A�m 3 LL c Pae of 1��+ Facility Address: City- Inspe ion D te: /" 0 6 &9A C,o� /5 GA/V© %�b FA#: PR#: Program le nt- Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum z 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: T : D J/—1 -7 73 (>250 gallons) (>55 gallons and<250 gallons) 1D Product Type: Total Capacity: 0 W gallons (per tank or cumulative for con iners by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TAM I 7 7 (>250 gallons) (>55 gallons and<250 gallons) 2 i] Product Type: Total Capacity: 0 gallons (per tank or cumulative for containers by product type) Install Date: Ek"Tank (2820) ❑ Containers (2821) #of Containers: TA#: 76 3 (>250 gallons) (>55 gallons and<250 gallons) v Vr Product Type: Total Capacity: -� Q 0 gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: 67j7-77& (>250 gallons) (>55 gallons and<250 gallons) / 4 Product Type: �_ 74 S Total Capacity: 60 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: 5 3 C1 ly gallons Total Capacity for Site: gallons Comments: Q Af -TL-? EHD Inspector: j� Reviewed Date: Entered Date: 1 4 -T By Initial: 'rlb,p� By Initial: ( rJ0 EHD 28-01 l/ A' 01/16/08