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, SAN.IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: y r- A A) Page of Facility Address: ity: Inspec 'on ru te: �- LT d ) FA#: PR#: Program E em nt: "Z—C? 1 #2 R C sac) --z $ 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 eroduct type. 2'Tank (2820) 11Containers (2821) #of Containers: TA#: �7 _ 1 Product Type: Y/ . Total Capacity: D gallons (per tank or cumulative for containers by product type) Install Date: L�-Fank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Tota! Capacity: � gallons (per tank or cumulative for ntainers by product type) Install Date: El Tank (2820) L1'Contain (2821) #af Containers: TA#: 3Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: i9 gallons Comments: EHD Inspector; Reviewed `. _ , Date: =Entered Date: sy initial: 'J ')-�� Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. v *"Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08 E