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SAN JOAQUIN COUNTY I NVIRONMENTAL HEALTH DEPARTMEN' r o00 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�-L�- 7 /�v C Y—) IV �, I��/ Page of Facility Address: City: Inspectie e: 6 hpra t Lo o 4� 5177Z -o /r-- ZD - FA#: PR#: Pragrata Element: �O 7 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: ,� _S— T,�AJ#: (,�� (>250 gallons) (>55 gallons and<250 gallons) �7��-CA 1 Product Type: l✓ Total Capacity: o © O a gallons Install Date: (per tank or cumulative for containers by product type) ❑ Tank (2820) RContainers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 112- 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) 3 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) 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: Total Capacity this Page: Z� 6 gallons Total Capacity for Site:f © gallons Comments: Ito I 4, Z o EHD Inspect Reviewed t Date: / Entered Date. By Initial: Vt �.25-Ot By Initial: EHD 28-01 0l/16/08