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r 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: 11r I ZO d % LL` S — -rG �o� Page of Facility Address: city: Inspectio Date: ?Ll-) v) L- C a og FA#: PR#: Program lejr/ep"� Tank/Container Information Comp! a 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. ig/Tank (2820) ❑ Containers (2821) #of Containers: r TRAM 1 / p g Product Type: n r Qom/ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 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 Total Capacity: gallons Product Type: (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: 'Ij I 0 gallons Total Capacity for Site: Z gallons Comments: L 3 Ile"' EHD Inspector Reviewed _I Date: Entered Date. �' + By Initial: �'" (t_�{-G By Initial: / � 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleums. "Container means a storage device designed to be moved when full. EHD 2801 AST SURVEY FORM 09/12/08