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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: e50 "al ri wG Page 2 of Faciliddress:O W /,^Vr City: Inspection Date N : 6�/Vryl wLl Q 1 l/ FA M 0 PR#: ProgranjElpmen 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#: �S�DlpS3' 1 Product Type: la.jo IP Total Capacity: Z D gallons v�tr'V` (per tank or cumulative for containers product type) Install Date: aCwJ'I d>n 47rve reo v l ,0-Tank (2820) ❑ Containers (2821) #of Containers: TA#:S-,5o?zPP&2 2 Total Capacity: rb d gallons Product Type: 6t, ,, K/ �1 . (per tank or cumulative for containers by product type) W d M' dJ Pi{'Vd1 f IMI Install Date: as rbia 12 ❑ Tank (2820) 'C-Containers (2821) #of Containers: TA#: D5aDD7� 3 Total Capacity: SS gallons ProductType:/{4a, l la)YpSStnr �Iti�vt (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: 5 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: 6l o'� l l By Initial: I (1 I (l By Initial: a/ /( *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 AST SURVEY FORM 09/12/08