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SAN JOAQUIN COUNTY 40 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: Page —L of-2— Facifi y Addre s: City: Inspection Date: lh � g l Dq- Z'5-- 1 FA#, PR#: Program Element: 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, Tank (2820) ❑ Containers (2821) #of Containers: TA#: � 1 Product Type: .Total Capacity: ,7 2-5gallonsyp p (per tank or cumulative for containers by product type) � �R Install Date: ,�� ,2—Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: allons Product Type: �'� e. 9 (per tank or cumulative for containers by product type) l�LJ�t.?70Y1 I/'0 — N I V) Install Date: Vu .P-Tank (2820) ❑ Containers (2821) #of Containers: TA#: 9 e20 j 9'j� eaL 3Install Date:Product Type: l Total Capacity: 356 gallons �^ gub (per tank or cumulative for containers by product type) OGd�,"�'1 c"-1 T ;VA tf —S Tank (2820) ❑ Containers (2821) #of Containers: TA#: D15-01?6 f 1' ) 4Product Type: Total Capacity: 9b gallons(per or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: Product Type: p Y� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallonsTotal capacity for Site: �� gallons Comments: 26 EHD Inspector: [Rreevi-ewed Date: Entered Date: 6L*?'�t nitial: (l17611 I By Initial: *Aboveground storage tank means a tank that has the c * � I apacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORIA