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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: P /? EK L n/T Page of Facility Address: Ci : Inspectlo Dat nZ ;,r 2 0 d FA 0: .� Q V PR k: Program El osa93 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. 9--Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: a D gallons (per tank or cumulative for teiners by producttype) Install Date: El Tank (2820) Ctontainers (2821) #of Containers:_ TA#: 2 Product Type: �C L� 0 Total Capacity: c', Z,Q 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 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: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: r L d gallons Total Capacity for Site: L gallons Comments: EHD Inspector: N Revievred _f Date: Entered Date: (_ By Initial: Wri ej-t'l-t7� 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. EHD 28-01 AST SURVEY FORM 09/12/08