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SAN JOAQUIN COUNTY ' ENVIRONMENTAL HEALTH DEPARTMEI 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 L/ /�,/� r s D E f 111 ePage 1 of Facility Address: City: Inspe t�175 n : g 0S /i'� ��L'nil� �/ G/q L-a Al � FA#: Pit#: Program Element: 000 T2s 53.323 12 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: 3 TA#: 1 (>250 gallons) (>55 gallons and<250 gallons) Q/ Product Type: Total Capacity: ,l O n gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ER Containers (2821) #of Containers: _ TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: 44 0 gallons (per tank or cumulative for conta' ers by product type) Install Date: ❑ Tank (2820) &(Containers (2821) #of Containers: S TA#: Q — (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: �/JQ S�'/, (3 Total Capacity: T7 gallons (per tank or cumulative for containers by product type) Install Date. b ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: 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: r Total Capacity this Page: gallons FTotal Capacity for Site: / gallons Comments: 173 - �3 �1 T ,✓ VAJepl It"30 EHD Inspector: Reviewed q Date:,% / Entered Date: C I �3 1pBy Initial: U� (0.1 By Initial: EHD 28-01 01/16/08