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SAN JOAQUIN COUNTY Y , ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s}gov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: /RAg 4,0'5s S . GI? �}�nd :Page / of Facility Address: City: Inspection a e: Z=29 t2 FA#: PR#: ,Program Element: ODI Zg� Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks* and containers**. Com lete one box for each tank or each cumulative container product type. Wank (2820) ❑ Containers (2821) #of.Containers: TA#: Total Capacity: �,� 7i gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: rygallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 11Containers (2821) #of.Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El-,.Tank 2820 ❑ Containers 2821 #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) 0Containers (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: �rY gallons -Total Capacity for Site: 3 '�/ gallons Comments: G 3 EHD Inspector: Reviewed Date: Entered Date: BInitial: � t( l`{�� 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 i AST SURVEY FORM 09/12/08