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SAN JOAQUIN COUNTY 3NVIRONMENTAL HEALTH DEPARTMEN- .,00 East Main Street, Stockton, CA 95202-302y Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 04 C,L1,?y PageZof42� Facility Address: City: C� Inspection D te: ►= T z Q7 FA #: c�z 9I PR #: Program Element- fl'eo PfSz3 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. a614l9`to1- o6/CaOq' VTank (2820) ❑ Containers (2821) #of Containers: TA#: a6 t o �' D lopQ'b 1 (>250 gallons) g6B gallons and <<?50 gallons) _ ,p Product Type: D L /L 4 O Total Capacity: 5'00 gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: / TA#: 05/ jj,,odr&e 2 (>250 gallons) (>55 gallons and <250 gallons) � Product Type: Lt/�J ST,o!�—' O/ Total Capacity: / Z b 0 O gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: & 0 3 (>250 gallons) (>55 gallons and <250 gallons) ✓ �� n 1 _G Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: L9 51 !o O 17 4 (>250 gallons) (>55 gallons and <250 gallons) �Product Type: OCL �' a Total Capacity: / O 0' 4 D gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 (>250 gallons) (>55 gallons and <250 gallons) Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) 19 Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: �- oda Als = TS a EHD Inspector: _ Reviewed Date: By Initial: Entered Date: By Initial: !�Q EHD 28-01 01/16/08