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r r SAP!JOAQUIN COUNTY �* ;H ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 F' Telephone: (209) 468-3420 Fax: (209) 466-3433 Web:www.sjgov.orglehd 4 ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 'T0 Page of Facility Address: Ci Inspect�o L Z 4(- !6/V Glj (V1 FA#. PR M Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers". Complete one box for each tank or each cumulative container product type. "Ink (2820) 1:1Containers (2821) #af Containers: TA#: 1 ?cit Product Type: Total Ca p y: 0:gallons r tank or cumulative for containers b e (Pe Y roduct P type) Install Date: �Tank�� (2820), ❑ Containers (2821) #of Containers: TA#: 2 Z-6 Product Type: il— S Y , Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ElTank (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: (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: U gallons Total Capacity for Site: gallons i . Comments: f l EHD Inspector: Reviewed Date: Entered Date: By Initial: 01 By Initial: 'Aboveground s orage tank means a tank that has the capacity to store 55 gallons or more of petroleum. I "*Container means a storage device designed to be moved when full. END 28-01 AST SURVEY FORM 08/12/08