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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: I— C C v D l L A Page �_ of Facility Address: City: Zl/ U� ff Date: Ins7/7;S7/o FA #:// 13 61 PR M Program Element: 'Za 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. 1 Tank (2820) ❑ Containers (2811) #of Containers: TA#: �c-� JO%<3 g/T 1 Total Capacity: 5(7,0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: c3 2 rr � Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Lb Tank (2820) ❑ Containers (2821) #of Containers: TSA#: 3 C Product Type: U`"�J / � Total Capacity: ,) gallons (per tank or cumulative for containers by product type) Install Date: EY/Tank (2820) ❑ Containers (2821) #of Containers: -TA#: ti )- 4 Total Capacity: j o0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: T #: � 5 Product T ype: Total Capacity: gallons (per tank or cumulative for containers by pr uct type) Install Date: Total Capacity this Page: ` Z gallons Total Capacity for Sitio: 3 gallons Comments: ffuA % 5 -fill b 6 T_ 1 EHD Inspector: C Reviewed Date:Entered By Initial: �u•-�� Date: By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum.' l **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08