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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Te%phone:(209) 468-3420 Fax. (209) 468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: C ` Facility�(dreas; p Page_ of City: Inspectiio Da FA#: (AJ P #: ro g Pram Element: Tank/Container Information 31 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. ank (2820) 13 Containers (2821) #of Containers: TAM 1 Total Capacity: gallons Product Type: 5 (per tank or cumulative for conlainers by product type) ��Q�i7�l &ftu . • G Install Date: 60 ❑ Tank (2820) Containers (2821) #of Containe q#: 2Product Total Capacity: _`� gallons Type: (per tank or cumulative for containers by product type) S Install Date: ❑ Tank (2820) Containers (2821) #of Container : _L T 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers bproduct type) Install Date: �rv`wI Tank (2820) ❑ Containers (2821) #of Containers: TA#: b,olr-1 Q $' a_ 4 Total Capacity: ��' yLb gallons Product Type: 01 (per tank or cumulative for containers by product type) Install Date: "Ato t rl51 rri�"-aiioiM Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: 15 1. -p (per tank or cumulative for contain type) tT»: tn5� e nG Install Date: Sgt Total Capacity this Page: gallons Total Capacity for site: D gallons Comments: EHD Inspector: Reviewed 1 Date: gEntlr'ld Date: By Initial: .�M-'�1 Dt.t l)•�O *Ab veground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. fJ *Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM