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SAN JOAQUIN COUNTY dt 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 C7S I r� S Af G Page � Of !r Facility Add ss: ty: Inspect' n Da : FA#: / / PR#: progrem"O a j�. Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (2821) #of Containers: I TA#: 1 {Total Capacity: gallons Product Type: 1 �� 1212 A ®i U (per tank or cumulative for containers by product type) Install Date:. ElTank (2820) 2 Containers (2821) #of Containers: TA#: /J 2 'Total Capacity: gallons product Type: (21 !� (per tank or cumulative for containers byproduct type) Install Date: k #of Containers: �� TA#: ❑ Tank (2820) Containers (2821) . _ 3 Product Type: Iif`!A S I i 0 Total Capacity: Z gallons - - - -— r (per tank or cumulative for containers by product type) ' Install Date: ❑ Tank (282D) El Containers (2821) #of Containers: TA#: -" ' 4 Total Capacity: gallons Product Type: } (per tank or cumulative for containers by product type) Install Date: t #of Containers: TA#: ❑ Tank (2820) ❑ Containers (2821) 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers byproduct type) Install Date: Total Capacity this Page: o gallons Total Capacity for Site: 60 gallons Comments: 13 71a l f 1=HD Inspector. Reviewed , ' wf Date: Entered l/� Date: By Initial: vk� �_1�-[� try Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 t AST SURVEY FORM 09/12/08 c F