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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: C %V C GT0rj r//ZA—` 57-AIIB, ►f # 7 Page—/ of_L Facility Address: City: Ins pectio Date: 6 , 14/ &� /© r�$ FA#: PR#: Program EI mant: 9!7 q OF I d5a -2. 0 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. Tank (2820) ElContainers (2821) #of Containers: TA#: 9 1 Total Capacity: �j.a'5�7 Product Type:gallons ... ,__ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: 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 Date: Entered Date: By Initial: VA _ C Sy Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleums. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09!12108