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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: F _ 0 OmC YAA05 lhl(� Page of Facility Address: City: Inspection Date: FA #: S r6 PR MProgram D �- Element: Z� Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. Ep.., Tank (2820) ❑ Containers (2821) #of Containers: TA#: A6/<°1p7 1t' () Total Capacity: S gallons Product Type: 2 a 5- /11 / l// L (per tank or cumulative for containers by product type) Install Date: Q Tank (2820) El Containers (2821) #of Containers: TA#: 2 /� � r Total Capacity: � 4 c gallons Product Type: (per tank or cumulative for containers by product type) Install Date: D Tank (2820) ❑ Containers (2821) #of Containers: TA#p 3 Total Capacity: �-_ OZ2- gallons Product Type: D (per tank or cumulative for containers by product type) Install Date: [''Tank (2820) El Containers (2821) #of Containers: TA#: _ �Q�S/ $ 4 f Total Capacity: � gallons 17--A S Product Type: L a (per tank or cumulative for containers by product type) Install Date: 171 Tank(2820) }'Containers (2821) #of Containers: _ TA#: 5 Total Capacity: c 7S gallons Product Type: 07 � (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2— SS_ gallons Total Capacity for Site: "� j��`�' gallons Comments: EHD Inspector: y � Reviewed Date:� By Initial: q-�(0^0° Entered By Initial: Date: *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 09/12/08