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SAN JOAQUIN COUNTY CNVIRONMENTAL HEALTH DEPARTMEN' 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 T S on/ //✓G Page / of Facility Address: o City: Inspection Dat �/' fy S�' Gi2G t f- S Tib $ l01 FA#: PR#: Prograifi E ement: Ziv7 1 827 3 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: TA#: (>250 gallons) (>55 gallons and<250 gallons) .� /�� 1 Z�oP Product Type: 4 77 Total Capacity: gallons Install Date: 164 � (per tank or cumulative for containers by product type) c� 4/Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: &6 Total Capacity: Z 1:400 gallons (per tank or cumulative for containers by product type) Install Date: CPfank (2820) ❑ Containers (2821) #of Containers: TA#: t95/7o12;7 (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: Z�U ) gallons (per tank or cumulative for conta4ers by product type) Install Date: ❑ Tank(2820) EikKontainers (2821) #of Containers: TA#: ),h (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: / / U 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: W3 I O gallons Total Capacity for Site: 23 It' gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: g i] EHD 28-01 v 01/16/08