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SAN JOAQUIN COUNTY 3NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: II //CC t`,,,,\\ I I iv / 14 l�( J� � u Page j of Facility Address: �� 9 Cit a�<� Inspection Da 2 6$� Laj FA#: CC I ^l-1 PR#: Program Elemen : 2�3 1 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) 1:1 Containers (2821) #of Containers: ` TA#: /(1250 gallons) (>55 gallons and<250 gallons) , 1 Product Type: ic' S- O"f 64 sol iry e 251 Total Capacity: /000 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) Containers (2821) #of Containers: ` TA#:�j�O51h q'p '7 (1250 gallons) ( 55 gallons and<250 gallons) 2 Product Type:E jox al (U`vo 10 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: (1250 gallons) (155 gallons and<250 gallons) 3 Product Type: `I At,) -�> Total Capacity: 1 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) fel Containers (2821) #of Containers: TA#: 7 (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: �Ytii�•2 �U•-':-�' �a of Total Capacity: [it) 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: '�� gallons Total Capacity for Site: ! gallons Comments: C�itr r, EHD Inspector: Reviewed te: Entered Date: By Initial: By Initial: o� D EHD 28-01 n 01/16/08 /�