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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 Nam : Page of ��n l Z r G� 1 - Mlq2i oS Facility Address: r n City: G In��ti nLD�tey 7 �J l/Q FA#: PR#: Pro ra amen Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks`and containers". Com fete one box for each tank or each cumulative container product type. ank (2820) ❑ Containers (2821) #of Containers: /_ TA#: 1 Product Type: !/� Total Capacity: 1� >/ gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: 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 Product Type: Total Capacity: gallons (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: �- i3 2t� lor✓s n X /r1�/Gi c.fA EHD Inspector: ReviewedDate: Entered Date: By Initial: vii 11.1,04 By Initial: I( ( 9 '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