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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: o P Al 9- � 3 �-- Page of Facility Address: z 2 Z JV- FL L/0 T ✓T r Inapeyyo!Date O FA#: O PR#: 3 Prog Drajrp E!'(syvo Tank/Contairl information �� Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. CZ/Tank (2820) El Containers (2821) #of Containers: � TA#: 1 Total Capacity: -/ y � V gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) L'J Containers (2821) #of Containers: TA#:Q 2 Total Capacity: ?,0,0 gallons Product Type: �d� (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) containers (2821) #of Containers: L TA#: / 3Product Type: STu e7/ L Total Capacity: S gallons (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: 7 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: C By Initial: vq� By Initial: 3 *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