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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: nD S ds /, , .T� L le, Ley Page of Facility Address: City: lnspectio Date: FA#: PR#: Program El rhent:U IV 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. Wank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: ,7 C�b gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative For containers by product type) Install Date: El Tank (2820) 11Containers (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: TAM 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: By Initial: P—)L 04)(.7 *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum.- "Container etroleum:"Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09112/08