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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: eN � ar✓� 141, Page of_L Facility Address: City: Inspection Date: FA#: 7 J Z PR#: Programa Iqemen ot: b � Z 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 ❑ Tank (2820) (XContainers (2821) #of Containers: (4 TA#: 1Product Type: V kD 01�Z Total Capacity: 2 2 V gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: 2 TA#: 2 Product Type: AJ eta O l Z- Total Capacity: 11 � gallons (per lank 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 36 gallons Total Capacity for Site: gallons Comments: EHD Inspector Reviewed Date: En�— . - Date: By Initial: p.q-D By IgIp O Abovegro d storage tank means a tank that has the capacity to store 55 gallons or ore opetroleum.- 'Container"Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM