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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. R 1l C 1� C o L Z-J T1 Q I Page of / Facility Address: City: Inspectl Date: 5 FA#: PR#: -v A Program E=lement: 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) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: Z � gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 11 Tank (2820) Ey Containers (2821) #of Containers: , TA#: 2Product Type: Total Capacity: / 0, 0-gallons -- •_ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) C7 Contalners (2821) #of Containers: _ TA#: 3n Product Type: tU OTd,lZ O/t"� Total Capacity: / 19 gallons (per tank or cumulative for containers byproduct 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: �j� 2� gallons Comments: r k1,4 S r [,00 tAA/r EHD Inspector: Reviewed Date: Entered Date: C By Initial: VA LO4x-d By Initial: g *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