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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: Page of C R�/0K sr Facility Address: City: Insibectio Da : C,A LDA/ Z 'T)q FA#: // PR#: Program Ele enll:/ 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: TAn#: 1 Total Capacity: �p�gallons Product Type: r O' (per tank or cumulative for containers by product type) Install Date: M/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: 3 O () gallons Product Type: 654 (per tank or cumulative for container;by product type) Install Date: ❑ Tank (2820) 0 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: gallons Total Capacity for Site: gallons ov Comments: EHD Inspector. Reviewed Date: Entered Date: i- By Initial: VA to,p By Initial: `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleu . "Container means a storage device designed to be moved when full. EHD 28-Ot AST SURVEY FORM 09/12/08