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v 1 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 Nam Page _ of Facility Address: City: Inspectio Date: i36 � � ago / c � LolJ 0 FA#: PR#: ProgfaM Elernarnti 7 7Z �6 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. E2/Tank (2820) ❑ Containers (2821) #of Containers: TA#:: 1 Total Capacity: � ��r- gallons Product Type: �� z (per tank or cumulative for conreipers by product type) Install Date: Cly Tank (2820) ❑ Containers (2821) #of Containers: TA#- 2 Total Capacity: 3 /) .5' gallons Product Type: / (per tank or cumulative for containers by product type) Install Date: El Tank (2820) 2tontainers (2821) #of Containers: _Z TA#: 3Product Type: Total Capacity: � �s gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) e-containers (2821) #of Containers: _� TA#: 4V 0 Total Capacity: 1� gallons Product Type: I (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Containers (2821) #of Containers: TA#: 5 Total Capacity: .! -.Irgallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z 0'0 gallons Total Capacity for Site: ZO gallons Comments: Z,,1--A1,cX11A,'41 Zo 3 P — 0V-bl EHD Inspector: Reviewed Date: Entered Date: By Initial: VA L�,'�t{- By Initial: '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. EHO 28-01 AST SURVEY FORM 09/12/08