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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN"I ..O� 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: CIO P 5� 7— A f} rk fj IA1 r { age Of Facility Address: / City: InspertiOQ Date: r4' // by I La FA#: zz Pa#: Program Ele t: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2,1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product C. ❑ Tank(2820) ontainers (282 1) #of Containers: J TA#: (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: 22 C, Total Capacity: vr,5 __gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (282 1) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and X250 gallons) 3 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) � Product Type: Total Capacity: gallons Install Date: (per tank or cumulative for containers by product type) Total Capacity this Page: S gallons Total Capacity for Site: gallons Comments: EHD lnspector: Reviewed Date: Entered Date: By Initial: By Initial: EHD 28-01 0I/10/08