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1. 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-dGlC TO H! S'T�{7lOPl y/ Page of Facility A ress: City: Inspection Date: o �) 0 FA N: PRN: Program Element: 3 Zoo6-918Baa Z9 v Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: , TA#: 1 Total Capacit 70 gallons Product Type: �� (per tank or cumulative for Containers by product type) Install Date: ,:2 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: - _ - gallons Product Typ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulabve for Containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for Containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: GUlgr/V"�-f-- /I/✓1011 obF/IeST EHD Inspector: Reviewed Date: Entered Date: - By Initial: O.'a"I• By Initial: /B�z `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more o petroleum. "Container means a storage device designed to be moved when full. EHD 2"1 AST SURVEY FORM 09/12/08