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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: �-► e -- Page of Facility Address:City: /Vc-A Inspecti9n Da } Y' l FA #: PR M 067305 Program Element: z b? "3n 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. El Tank(2820) CKontainers (2821) #of Containers: TA#: 1Product Total Capacity: / �✓ gallons Type: yp (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) L3'Containers (2821) #of Containers: J TA#: _ 1-951 qR� 2 — Total Capacity: % Z.� gallons Product Type: �v �4 f (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: qP 3 / Total Capacity: � gallons Product Type: �;' �� 1 r- D� C__.) (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ontainers (2821) #of Containers: 7— TA# 4 Total Capacity: ,/ � gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) E-dontainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: , r, Reviewed Date: Entered Date: By Initial: By Initial: Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleurr(. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09n ?Ins