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SAN JOAQUIN COUNTY ,NVIRONMENTAL HEALTH DEPARTMEN7. 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 F4 k A f C C Page of Facility Address: Cit Inspect' n Date 1J � M I CI>� ��o � zp/�B FA#: o �� PR#:D-6'z� O Progr�a�m Element* Tank/Container Information G. 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. Lank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: S'�Li r //.� Total Capacity: O O gallons 4 (per tank or cumula for containers by product type) Install Date: �nk (2820) ❑ Containers (2821) #of Containers: TA#: 2 (>250 gallons) (>55 gallons and<250 gallons) Product Type: IC-171 Tip Total Capacity: .-o d gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) L9"Containers (2821) #of Containers: TA#: 25177 oU S (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: Z, S'o gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) J 4Product Type: �f.sly� d Total Capacity: Z Sd 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: /see gallons Total Capacity for Site: 0 e) gallons Continents: EHD Inspector: _ Reviewed Date: ./ Entered Date: By Initial: $.��1 0{ By Initial: EHD 28-01 01/16/08