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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: % /' nJ - (�,0 Page of Facility Address. City: Inspeti n Date: r •L,i X6 . FA#: PR M Progra t Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks' and containers"*. Complete one box for each tank or each cumulative container product type. Tank (2820) ElContainers (2821) #of Containers: TA#: Qom )$9 1 Product Type: Total Capacity: t)--�' gallons (per tank or cumulative for c ntainers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: it O gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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.- El ate:❑ 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: ' z CK>O gallons Total Capacity for Site: L, gallons Comments: EHD Inspector: Reviewed , ^ ^J Date: Entered Date: V By Initial: im -y• t By Initial: "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 AST SURVEY FORM 09/12/08