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J 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: � w 0 N i 1SN � L`� i �, l Ud (`Oq ir� Page -2— of Facility Address:City: Inspe tion D te: FA #: PR #: Program Element: 2- e,3 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks` and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: D 5 i 77 9Q 7 1 Total Capacity: (' D0iJ gallons Product Type: U�Qf / L (per tank or cumulative for containers by product type) Install Date: 'K Tank (2820) ❑ Containers (2821) #of Containers: TA#: 05-1-7225 2Product Total Capacity: (S U gallons Type:y �b 0/_L (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.- ate:❑ 0Tank (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: I o5`00 gallons Total Capacity for Site: —7 b gallons Comments: EHD In or: Reviewed By Initial: Date: Entered Date: By Initial: "Abovegrounb 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