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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: r- 9c'pl'?e/,%I -'V1 Z/ b�'��-� Page � Facility Address: Ci � r --D t' -/71D S - Inspec 77/77� FA #: PR #: 7 Program Element: 7=� P 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: TA#: 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 1,46ontainers (2821) #of Containers: TA#: 2 Total Capacity: p y: gallons Product Type: f��N X61- 1 —T� (per tank or cumulative for c(rtainers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: p y: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 0 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: ` P y "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