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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT l a 600 East Main Street,Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd : ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: s, x-11= A A16 Page T of Facility Address: city: Inspection Date: FA#: PR Program Element, Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?-1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. I'f Tank (2820) ❑ #of:Containers: TA#: Containers (2821) o 1 i Product Type,, n Total Capacity: gallons --�� — (per tank or cu1`mulative for containers by product type) Install Date: II WTank (2820) ❑ Containers (2821) #of Containers: TA#: 2- Product Type: Total Capacity: ��_gallons --° (per tank or cumulative for containers by product type) Install Date: 7; P"Tank (2820) ❑ Containers (2821) #of Containers: TA#: u 3Total Capacity: 2-N—V gallons Product Type: (per tank or cumulative for containers by product type) Install Date: #ofContainers:-' TA#: `7 El Tank (2820) L- containers (2821) . - ----- 4 - ProcJuct Typrr Total Capacity: — _ � `gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type; _ (per tank or cumulative for containers by product type) Install Date: Total Capacity thin Page: �'2�0 gallons Total Capacity for Site: �� gallons J Comments:. t1N COT/ ESA-1 !ele Gr 9/vl,�/� .T ILx r' EHD Inspector: Reviewed Date: Entered Date: By Initial: �.�t�, By Initial: , *Aboveg round�storage tank means a tank that has the capacity to store 55 gallons or more of petroleu . **Container means a storage device designed to be moved when full. EHD 28-01 l AST SURVEY FORM 09/12/08 -� f