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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 Facility Name: / A piloil IG ivS s�rGGrO' l�Dlrr Page --�— of Facility Address: City: maps tion 01te: `131 7 or w�l dG LI !YO� FA#. -70 4r7CI PR#: Program Element: 6 k 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#: 1 Total Capacity: Product Type: p Y: � � D gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: Z TA#: 2 Total Ca acit Product Type: p y: gallons (per tank or cumulative for con amers by product type) Install Date: ❑ Tank (2820) XContainers (2821) #of Containers: �_ TA#: 3 Total Capacity: gallons Product Type: Ill n)4op<, (per tank or cumulative for contain type) Install Date: ❑ Tank (2820) !Nocontainers (2821) #of Containers: Cy TA#: 4 Total Capacity: 2 2 y gallons Product Type: N 16,11`0 012. (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 5 Product Type: 771 )Aj"6;A,Total Capacity: l l u gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: Zgallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: arl I By Initial: �lr I/ *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 09112'08