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. SAN JOAQUIN COUNTY . 4 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 / Of Facility Address: f City: Insp cti(n�jttb Aazzqfy FA#: PR#QSa�a 73 ProIgq(1er1�Y7,},: 49q2Tank/Container Information �f4� 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#: _ 11 i� Total Capacity: -S�' � gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ET/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: 3 SO gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Z.�-�I ank (2820) ❑ Containers (2821) #of Containers: TA#: 3Product Type: S 7 Total Capacity: `( .S -e,2 gallons (per tank or cumulative for containers by product type) Install Date: � "� El Tank (2820) 2/containers (2821) #of Containers: TA#: 4Total Capacity: �� gallons Product Type: r<' (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: Z- S gallons Comments: ! -3 41111 IV S EHD Inspector: „ Reviewed Dale: Entered Dale: By Initial: V11,13 �.,5• D� By Initial: c- *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