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`, SAN JOAQUIN COUNTY *..Oe 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 —L of Facility Address: �� City: Inspectio t // 35'1 F - 2c �� , 0 FA f PR M: Pro ram EI ent: oU 6 5 a'? a f� Tank/Container 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, a Tank (2820) ElContainers (2821) #of Containers: TA#: 1 Total Capacity: 0O gallons Product Type: p (per tank or cumulative for containers by product type) Install Date: a,'tank (2820) ❑ Containers (2821) #of Containers: TA#: �/ 2 Product Type: �.f Total Capacity: SGp 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: gallons Total Capacity for Site: �� gallons Comments: EHD Inspector: Reviewed 11 Date: Entered Date: _ By Initial: �/vtv 1 r,-7v�-a� By Initial: a t v '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 2&01 AST SURVEY FORM 09/12/08