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01' SAN JOAQUIN COUNTY Ole 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:/ , / Al =/ !/ fi � © N ��/ Page of Facility Address: City: InspectIn T rS Z100 5'. � � � FA#: PR M Program Element: 6 © '3oA Z 8 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#: 22- 1 Product Type: Total Capacity: ,��® gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: iTA#: 0,61-3 7 Z$ 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers y product type) Install Date: [Y'Tank (2820) ❑ Containers (2821) #of Containers: TA#: �,h/T 7�� 3Product Type: Total Capacity: � gallons (per tank or cumulative for containers by product 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 Pagel O o gallons Total Capacity for Site: p gallons Comments: EHD Inspector: Reviewed Date: Entered Date: •J By Initial: -�.�Q.o� By Initial: "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