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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: p OI tq v Dr- Page l of Facility Address: city: a Inspection Dat ��2 o� / B 1 '�m9 FA#: PR#: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks*and containers". I Com fete one box for each tank or each cumulative container product type. #of Contaihers: TA#: 12"Tank (2820) ❑ Containers (2821) A 1 Total Capacity: gallons product Type: _ (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers-(2821) #of Containers: TA#: l 2 Total Capacity: �j gallons product Type:` t (per tank or cumulative for containers by product type) Install Date: t Tank (2820) El-Containers (2821) #of Containers: TA#: 3 Product 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: a ElTank (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: 1/ 05 gallons Total Capacity for Site: 9� gallons Comments: �p EHD Inspector: Reviewed Date: Entered Date: By Initial: ��,tC� By Initial: 7 *Aboveground storage tank means a tank that has the capacity.to store 55 gallons or more of petroleum. OC ' "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORMA 09/12/08 i i