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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 � S Page of Facility Address:, City: Inspec 117 Date FA#: / > 0 PR#: — Program EI m@nt: 6 30 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. Tank (2820) ❑ Containers (2821) #of Containers: TA(#: - 1Product Type: Total Capacity: ��P gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TAn#: 2S Product Type: F-2-OL"Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: �c' (�l �'J �7 3 Total Capacity: 5.; gallons Product Type: .J' %� 0/ L/ (per tank or cumulative for containers by product type) Install Date: ElTank (2820) 2,containers (2821) #of Containers: TA#: 4 0Product Type: /77v Zb/7— Ol Total Capacity: /70-de gallons (per tank or cumulative_ ;,mi ,by product type) Install Date: ank (2820) ElContainers (2821) #of Containers: TA#: 5Product Type: Total Capacity: /_ gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed � � Date: Entered Date: By Initial: j"�( 0.01 By Initial: '2 l� *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08