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SAN JOAQUIN COUNTY YNVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,-Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: C 1 S I T'l 0 A/!G 1"'fq Page�L of Facility Address: City: Inspection Date: 3 �09 FA#; PR#: Program Elem t: 9- / -3� z Tank/Container Inforniation Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers". Com fete one box for each tank or each cumulative container producttpe. P Tank (2820) ❑ (Containers (2821) #ofi Containers: TA#: 1 Total Capacity:_gallons Product Type: =�j�{S R � (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: ' TAlt: 2 Product Te: Total Capacity: � gallons yp (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: El Tank (2820) ElContainers (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: gallons Comments:X EHD Inspector: Reviewed Date: E2n . ntered Date: By Initial: �,�� By Initial:"Aboveground storage tank means a tank that has the capacity,to store 55 gallons or more o petroleum. XP *"Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 08!12108