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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 r-0ott S i r>e,, �D u� h �il�� Page 4— of Facility Address: City: Inspection Date: ( �3 p vGL l ( Id 5 FA#: D '1 PR M — Program Element: V 1 293 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. l Tank (2820) ❑ Containers (2821) #of Containers: 1 Total y: gallons Capacity: 608 Product Type: p (per tank or cumulative for containers by product type) Install Date: L e-) 1 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: S_6 U gallons Product Type: (per tank or cumulative for containers by product type) Install Date: - / J4-7 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: ��- b I Z. Total Capacity: gallons (per tank or cumulative for ontainers by product type) Install Date: pl cj ElTank (2820) ,Containers (2821) #of Containers: ' I� TA#: 5sa 4 0 Product Type: t`i Q/�1i l/Z OIL Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 5 Product Type: �� ' �_1 L /S- (per r' �d Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: 2�� gallons Comments: EHD In ector: Reviewed Date: Entered Date: By Initial: By Initial: 16 *Abovegrou d storage tank means a tank that has the capacity to store 55 ga Ions or more o petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08