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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: 15 J t. � N Page _L_ of Facility Address: City: Inspectl Date: � To 0 FA#: PR MProgr m Elem nt: 512- OS2a l 6LD Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers". Com fete one box for each tank or each cumulative container product ty2e. On/Tank (2820) ❑ Containers (2821) #af Containers: CP TA#: 1 i.14 , Total Capacity: Z gallons Product Type: (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: 9 ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons , k (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of. Containers: TA#: !lr 5 Total Capacity: gallons Product Type:: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: -L �40 gallons Total Capacity for Site: gallons Comments: t EHD Inspector: Reviewed , - �1 Date: Entered Date: , By initial: By Initial: *21X X "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 Et AST SURVEY FORM 09/12/08