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a.► SAN JOAQUIN COUNTY 'we 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: �ToC k 7-0W F1iff S TA T,'O /v Page of Facility Address,1,P0 n/t City: (� /L Inspection a e 7(0 FA#: 7 A PR 0: �7��ry '/ Program mentll 1[7 Tank/C!/ontaaiineroICnfoormation [f i 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) ❑ Containers (2821) #of Containers: A# 1 Total Capacity: 0 0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (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: ❑ 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: Szl'l gallons Total Capacity for Site: gallons Comments: L/cir EHD Inspector: Reviewed Date: Entered Daten By Initial: 0�_e� By Initial: 1 B A 'Aboveground storage nk 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 09112/oe