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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: 120iLlAt,D —J- R j h l4tReT Page of Facility Address: City: Insp tion Date: FA#: PR#: Program EI ment: 00 ( ? D5 '3o 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) El Containers (2821) #of Containers: TA#: �1 7 3b I 1 ��'7 Product Type: fnu Total Capacity: l cgallons (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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 0 d () d gallons Total Capacity for Site: 40 Q 45 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: ' By Initial: By Initial: q *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of Oetroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/1 2108