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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: ll D O d3k q 5S ,oM �i Page of Facility Address: City: Inspect' n D te: �Nc")1 c� �► 7'" FA#: PR#: Program EI ment: 6 2-J ( -0 5 30 I �. 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. 19/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: � �J�� gallons (per tank or cumulative for c tainers by product type) Install Date: ED/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 69115-/ 2 Product Type: Total Capacity: 0gallons (per tank or cumulative for containers by product type) Install Date: I/ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 �r Product Type: Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: I ank (2820) , Containers (2821) #of Containers: //TA#: p 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: f f` gallons Total Capacity for Site: r�S S gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: 1-\A,0By Initial: "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