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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: O r� , Page _ of M 5 Facility Address: / City: Inspection pate• S psA � -0 o2 FA#: Program EI ment::' t7 L� 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. VTank (2820) El Containers (2821) #of Containers: TA#: D 6i 1'-7g30' 1 �% - ��C) gallons Product Type: > V4 ') Total Capacity: (per tank or cumulative for containers by product type) Install Date: I/ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4�5 ) Product Type: i 2A D V 2 Total Capacity: S rL4 gallons (per tank or cumulative for containers by product type) Install Date: V/Tank (2820) El Containers (2821) #of Containers: TA#: Product Type: 3 Total Capacity: ✓ gallons ✓— (per tank or cumulativeforcontainers by product type) Install Date: #of Containers: TA#: Vfank (2820) El Containers (2821) G16 !`I q 3 4 (- , i9 Product Type: /k'V Total Capacity: ? gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) El Containers (2821) #of Containers: TA#: 5Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: allons Total Capacit for Site: gallons Total Capacity this Page: p t7 g y Comments: EHD Inspector: Reviewed 1 Date: Entered Dater By Initial: 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. AST SURVEY FORM EHD 28-01 09/12/08