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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: „w(, -i � _ N Page +I of 0 Facility A ddress / City: / Inspection Date: 4 �(�L(GTO�. I �— 10 FA#, PR M: Programpe / 1 5-2" -5- 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. NbTank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: l ksa� o I Total Capacity: �Sd gallons (per lank or cumulative for containers by product type) Install Date: E' Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: // p gallons Product Type: S� --2— (per tank or cumulative for containers by product type) Install Date: J$ Tank (2820) ❑ Containers (2821) #of Containers: /1 TA#: 3 � �-, Product T e A�� Total Capacity: � gallons yp (per tank or cumulative for containers by product type) Install Date: A Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4Product Type: 1 —3o h-o4W' o Total Capacity: 7 2 gallons yp 51-. ) (per tank or cumulative for containers by product type) Install Date: N ' Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: I /C�> gallons Product Type: �T r (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: 6 gallons Comments: Qegg Reviewed Date: Entered Date: By Initial: . .. , .. By Initial orage tank means a tank that has the capacity to store 55 gallons or more of petroleum. "Containe means a storage device designed to be moved when full. END 28-01 09/12/08 AST SURVEY FORM