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SAN JOAQUIN COUNTY �VIRONMENTAL HEALTH DEPARTMENT uu0 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: Pa g e of 1—� C N�R r KY Facility Address: e ` If�ty. 5 TA Insp�tfn FA#: PR#: Program Element: 21 o_�::1 9? ?(";';'2- 1 z s3 Z,- 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#: D5-17,`d 7 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: D,,L� Total Capacity: 0 D D gallons (per tank or cumulative fo containers by product type) Install Date: Eg/Tank (2820) ❑ Containers (2821) #of Containers: TA y! X702 R'g' (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: /0 4 d gallons (per tank or cumulative for containers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: D51�pZ 8L'J (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: /Q.S' 002 Total Capacity: /D 00 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) VJ Containers (2821) #of Containers: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: S S gallons (per tank or cumulative for containers by product type) Install Date: 5a"'Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: 1j/4 CTP Q . U Total Capacity: gallons (per tank or cumulative for contai._ oy product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: Z O S Z gallons Comments: EHD Inspector: t Reviewed Date: Entered Date: By Initial: `,,�I I,b,�� By Initial: _4e EHD 28-01 vv,, 01/16/08