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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.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM [FA lity Name: ��1GC.f Page 2 of 2 ity Address: City: a5Jv tom. L/, - '1 �G7 (]� e_�n Inspgc on Da a-� Q : J r�KJ / U �U�-lc-r Cl PR#. Program Element: �� 5-e 6 5 2 /?j 28"3/ Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks'and containers". Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (2821) #of Containers: 2 TA#: t, ?/9 1 Total Capacity: �5 gallons Product Type: _ � (per tank or cumulative for containers byproduct type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank orcumulaliveforwnlainers byproduct type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulaflveforwntainers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Total Capacity: gallons Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons yp ' (per tank or cumulative for containers byproduct type) Install Date: Total Capacity this Page: r�5 gallons Total Capacity for Site: �(P(� - l �S gallons Comments: EHD Ins otor. Reviewed Date:�/ i Entered Date: By Initial: (RIA Li y 'Abogr nd storage tank m s a ank that has the capacity to store 55 gallons or more of petroleum. "Co mer means a storage device designed to be moved when full. EHD 2a-01 0911210E AST SURVEY FORM