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I f 4 4 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-34.20 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: C r�/�JzJl/V�TO� /"/2� /✓f S>�nf Page ofd_ Facility Address: Zf�4 57 0, pec City: insion to: FA#: Thi�J O Progr em nt: 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. Ll' Tank (2820) ❑ Containers (2821) #of Containers: TA#: ` 1 Total Capacity: Zr49 Product Type: e: � -"' - •��-=�.. ,_... .�_ (per tank or cumulative for containers by product type) 2--Tank � Install Date: S� . 2" Tank (2820) ❑ Containers (2821) #of Containers. _ _ TA#: 2 Total Capacity: —Z—1-0 gallons Product Type: _ S".- 6 ._ / . (per tank or cumulative for containers by product type) Install Date: S ya1 /7- '74,&16 ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (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: /LEY mob . D EHD Inspector: ��''}} Reviewed Date: �Enter!edDate: By Initial: 1n� r` ,��, c1 *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. 7 "*Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM asci 2108 r