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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT o00 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: O &A Cr A R oS Page of Facility Address: Cit Inspection D te: 2,3 �S L✓ ST c�,�r� � �d,D� i�-- � � � FA#: PR#: PElemeQt:® � 9 '9 96-c-v Program� 8 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_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: TA>,#: (>250 gallons) (>55 gallons and<250 gallons) 1 - Product Type: Total Capacity: 1 0 gallons (per tank or cumulative f6r containers by product type) Install Date: VTank (2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: J-0 (9 gallons (per tank or cumulative for containers by product type) Install Date: M Tank (2820) ❑ Containers (2821) #of Containers: TAM Go (>250 gallons) (>55 gallons and<250 gallons) n 3 Product Type: S Total Capacity: '�e,!� gallons (per tank or cumulative for containers by product type) Install Date: EVTank (2820) ❑ Containers (2821) #of Containers: TAM -7 (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: - ��V_ 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 Total Capacity for Site: o (I gallons Comments: EHD Inspector: Reviewed Date: Entered Date: r By Initial: vpj By Initial: U� / EHD 28-01 �` t 01/16/08