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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN 600 East Main Street, Stockton,CA 95202-302-Y Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: � � 0 or- Cil4 L � �rQ l� 1 r� Page I of Facility Address: City: Insption Da 2-3 k1 c- Y i Ic. c ti 9-5,74gri 9 0 FA#: PR#: Program Element: o � 3P 3 1 2831 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) # iners: TA#: P (>250 gallons) (>55 gallons and<250 gallons) 1 O 'a Product Type: Total Capacity: 1 gallons (per tank or cumulative for containers by product type) Install Date: L C�1C Tank (2820) ❑ Containers (2821) #of Containers: TAM /7Q (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: O o e? gallons ,�_, � (per tank or cumulative or containers by product type) all Date: (,6 ZG 1 fel - " �0^ f� Tank (2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: 19 f Total Capacity: J+o d gallons Com: ��` i (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'rQ 6 gallons Total Capacity for Site: Z r_90 gallons Comments: EHD Inspector: - Reviewed Date: Entered Date: ' By Initial: �-LO OC( By Initial: EHD 28-01 i 01/16/08