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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 f r I `'l `�' 2- Page —L of Facility Addres0 w �,�1"�� City:S � Inspe tion Daj FA#: PR#: Program Ellelm/ent: tv � -7 r.5r o 2 � � 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#: 1Product Type: In /4X 4-2 6 Cy Total Capacity: 'L Z 0 gallons (per tank or cumulative for containers by product type) Install Date: I-}NIL sw-') ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) 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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: D gallons Total Capacity for Site: 2 2U gallons Comments: U q w � l EHD Inspe=r Reviewed Date: Entered Date By Initial: a_t�. By Initial - "Abovegrou d 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 29-01 09/12/09 AST SURVEY FORM