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SAN JOAQUIN COUNTY U ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: �9Ajq n � Page of Facility dress: City: Inspecti n Dat . 0 3S - Irv. s, z FA#: PR#: Program Element: 0 195E4 & :. 2 g Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container eroduct type. aTank (2820) ElContainers (2821) #of Containers: TA#: 1 Total Capacity: allons Product Type: f5� 9 (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: E 11 Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) 11Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: a ❑ 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: J 090gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By initial: S-��l-� By initial: �� oZl¢ *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 09117/08