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• SAN JOAQUIN COUNTY . ENVIRONMENTAL 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: n C C L G 1� S l Page C of Facility Address: , ��i y: Ins ctio tb © i _ 7 FA#: 11- g PR#�5a�a 73 Pr3:14?- 7 gra 1941ent >�J Tank/Container Information —i/�NH- Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks"and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: a 1Product Type: Total Capacity: .S0 6 gallons (per tank or cumulative for containers by product type) Install Date: DerTank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: 3 Spgallons Product Type: _ zpx-Ut-e"L' �(petank or cumulative for containers by product type) Install Date: dam'`I ank (2820) ❑ Containers (2821) *of Containers: TA#: 3 Total Capacity: S� gallons Product Type: _�,�f, SIf� (per tank or cumulative for containers by product type) Install Date: ❑ Tank 2820 ( ) #of Containers: TA#: ( ) Containers 2821 4 r• Product Type: Total Capacity: � � gallons (per tank or cumulative for containers by product type) Install Date: 1§ Tank (2820) ❑ Containers (2821) #of Containers: TA#: A c?gr1-6 5 —gallons Product Type: Ct i Total Capacity: Z (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: - gallons Total Capacity for Site: —�✓ - gallons/ Comments: (! ! le l / EHD Inspector f�'/ Reviewed Date: Entered Date: By Initial: Uji 0� By Initial: �7 // 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08