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✓� SAN JOAQUIN COUNTY `..i '"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: .Ie ,r= AsOrJ UCC uTT/ tvr, Page � of� Facility Add as: Cfry: Inspectio Date: n Wf 1 0 F FIN r R`D�/h ryGn/ J�� / m FA#: I �B / PR OV .7 1 Dpi oC. Pro9 I t: 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- 2/Tank e. 2" Tank (2820) ❑ Containers (2821) #of Containers: TA#`:y 1 r Total Capacity: _.Z O gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Ck"Tank (2820) ElContainers (2821) #of Containers: TA#: 2 — Product Type: �I x f Total Capacity: gallons (per tank or cumulative for coffainers 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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: (� gallons Total Capacity for Site: gallons Comments: C G 14 IL oo 6 ^ i° '�4 EHD Inspector: Reviewed Date: /: Entered Date: By Initial: 1d.�'\, By Initial: l 191,�4� '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