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ti N.. - ENVSAN JOAQUIN COUNTY R RONMENTAL HEALTH DEPARTMENT' �'4 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209) 468-3420 Fax:(209)468 U33'Web www.sjgov.org/ehd 'ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY'FORM,.. Facility Name: -" e � 0 :_7 Page of Facility Address: city: Inspection Date: 2Z_K© � S� r_ - r�C 1o1 FA#. PR M IProgramElement: Z j _o Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum al,320 gallons in tanks*and containers"*. Complete one box for each tank or each cumulative container product type. VTank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: "L0-0 gallons Product Type: �g (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers:. TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers:' TA#: 3 Product 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 Page: gallons Total:Capacity for Site: Ze-;R--0 gallons Comments: J EHD Inspector: ReviewedDate: Entered Date: � � N� By Initial: t 1`151• By Initial: Q 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 3 AST SURVEY FORM 09112108 ti