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,. Y •aF SAN JOAQUiN COUNTY . 4NVIRONMENTAL 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: Page of Facility Address: City: Insperon D 14 a ? "1" A D 1 FA#: PR OPJ Programlernt; , aSir &963D lY7 fG�/►t"/ Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2:1,320 gallons in tanks*and containers**. Com fete one box for each tank or each cumulative container product type. ON Tank (2820) 1:1Containers (2821) #of Containers: TA#: 1Product Type: Total Capacity: Z� 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 conta'ners by product type) Install Date: / ❑ Tank (2820) ❑ Containers (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: t (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (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: 2 gallons Total Capacity for Site: gallons Comments: r9'r4 Alli �js' 0 t9 7b� SU e � — EHD Inspector: Reviewed Date: Entered Date: By Initial: `�,�. By Initial: PT ir/)0 2A,t� I *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. EHO 28.01 AST SURVEY FORM 09/12/08