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SAN JOAQUIN COUNTY ""ENVIRONMENTAL HEALTH DEPARTMENT'S 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: (� l�A& 1 ;,oh O Page ( of Facility Address: City: Inspe tion Date: b S• 4u2U 5� s G LA-*%j 1/ 66700 FA M PR#: Program Element: X103 3 21ff Lo 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) XContainers (2821) #of Containers: 2 TA#: 1 Total Capacity: 1 1 b gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) gContainers (2821) #of Containers: TA#: 2 Product Type: N 45UNJ D% Z Total Capacity: �_gallons (per tank orcumulative for containers by producttype) Install Date: ❑ Tank (2820) Containers (2821) *of Containers: TAM 3 Total Capacity: 50'�' —gallons Product Type: bl PSL Pyo (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 5 Product Type: Total Capacity: gallons (per lank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 2 O gallons Total Capacity for Site: Z gallons Comments: EHDector: Reviewed , • Date: Entered Date: V By Initial: v`_�' It k. By Initial: `Abovegr and 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