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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME1 600 East Main Street, Stockton,CA 95202-30 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: // ,SC �/I ✓/� T G 14 C/ Page-L°f Facility Address: City: Inspecti n D9e: T? NS a 2 7 J o K/ CST r-k FA#: ©� PR#:s-/e Programp eme� ZO Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum Z 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: TA#: (>250 gallons) (>55 gallons and Q50 gallons) 1 Product Type: [? Total Capacity: ,j p DO gallons (pe"tank or cumulative for containers by product type) Install Date: I Tank(2820) El Containers (2821) #of Containers: TA#:Q (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: So 0 A gallons (per tank or cumulative for containers by product type) Install Date: El/Tank (2820) ❑ Containers (2821) #of Containers: TA#: D5 Ke lq (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type:W.4 S'Tt d(/J Total Capacity: gallons (per tank or cumulative for ontainers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: e,5a,- ,- (>250 gallons) (>55 gallons and<250 gallons) � 4 Product Type: p / Total Capacity: /S" gallons Install Date: (pr tank or cumulative for containers by product type) 6 erTank(2820) ❑ Containers (2821) #of Containers: _ TA#: Z,9,-j/le 1 (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: 6 y Ci Total Capacity: /s0 d gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: (j gallons Total Capacity for Site: S 0 gallons Comments: EHD Inspector ` Review _� [e: [erect D te: By Initial ` By Initia � O EHD 28-01 / 01/16/08