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r 1 9.F 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 5- �►'A)' '� 3 l / Page of I, Facility Address: j City: Inspection Date: Z96 iE C/,-"7-LE 4f L/ 6T" - Z— o FA#: PR#: Program Element: 0 ZJ TanklContainer Information Complete for-all sites with cumulative aboveground storage of petroleum Z-1,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container product type. Eb"<ank (2820) ❑ Containers (2821) #of Containers: TA#: Product Type: Total Capacity: 5 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 010ntainers (2821) #of Containers: TA#: �77 2 Total Capacity: gallons Product Type: ,�_ 7�2 Dy (per tank or cumulative for con finers by product type) Install Date: ❑ Tank (2820) ontainers (2821) #of Containers: TA#: 3 Product Type: )"L� . r} Total Capacity: gallons (per tank or cumulative for contSinearby product type) Install Date: ❑ Tank (2820) ❑ Containers (2829) #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: gallonsl Total Capacity for Site: 10 gallons Comments: EHD Inspector: ti Reviewed Date: Entered Date: be ByInitial: - By Initial: 0 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 t' AST SURVEY FORMq 09112108 ¢