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SAN JOAQUIN COUNTY r ENVIRONMENTAL HEALTH DEPARTMEP' 00 East Main Street, Stockton,CA 95202-3 Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/chd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / C ✓Lr/1 /� .T 6 A C/ Page_� of r_ Facility Address: _ Cit Y: Inspection Dae: TR nl s a21 / dr✓ FA#: PR#: ProgramElement: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 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#: ��/(P/ (>250 gallons) (>55 gallons and<250 gallons) Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: I Tank(2820) El Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 ! V0 p Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: En Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: /,/,tJ S?A d f/J Total Capacity: �gallons (per tank or cumulative for ontainers by product type) Install Date: Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: p / Total Capacity: )'s" gallons Install Date: �(pr tank or cumulative for containers byproduct type) LSA/Tank (2820) ❑ Containers (2821) #of Containers: I��__, TA#: (� Ile(p 1 �� (>250 gallons) (>55 gallons and<250 gallons) I"wr+ 5 Product Type: C5 i Total Capacity: /100 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: (2 p gallons Total Capacity for Site: 5 0 a gallons Comments: EHD Inspector ( Reviewed _� [e: [erect te; / By Initial ` By Initia O �( 21 f / � / UUU EHD/08 � /_ 01/16/08 (S�r (/