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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 c.-cu (t-0 n eVyuj Page of Facility AOdress: city: In70-7 - 11 n Date: r '; Lill PAtiPAfl 2,113 FA#: PR#: Program Element: 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#: 1 Product Type: Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date:-01" 11N�tnJ� Tank (2820) ❑ Containers (2821) #of Containers: TA#: Z` Oat Z 2 Product Type: k'U�j,r GL'j` t C- Total Capacity: ��0 gallons --7 (per tank or cumulative for containers by product type) Install Date: J2'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1fHaDo,s� 3 Product Type: L I I:,_(,t)—� E D Total Capacity: ��'} gallons (per tank or cumulative for containers by product type) Install Date: t)t4y-",, Tank (2820) ❑ Containers (2821) #of Containers: `` TA#: �P 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: (V _ 'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: Product Type: )✓'L2'� C-) p y: �OCA gallons (per tank or cumulative for containers by product type) Install Date: 0 P\L� Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed . Date: Entered / Date: . / By Initial: j< ,r `ii" �1 1\ By Initial: Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. l —Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM