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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: / _ n 1 f Ct-D �e �NGlikj, " Page of? Facility Address: City: Ins ction Date: ` �"er,' leiFA#: PR C Program Element: 5 Z 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) *ontainers (2821) #of Containers: 10.y TA#: 1 Total Capacity: "jy�(o gallons Product Type: to R? AZA4 ,,j4.� (per tank or cumulative for containers by product type) v`0�1Z01aY�- Install Date: ❑ Tank (2820) kContainers (2821) #of Containers: 2 TA#: I� 2 Product Type: cr,4 lO"d e sk, Total Capacity: D gallons (pertank orcumulative for contain product type) �'V I C H �' �ETy yA�' VZ Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Zb gallons Total Capacity for Site: 2 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: ' � O "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