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r 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: C�AIU20,-Z-8 966UP Page Facility Address: City: Inspection Date: FA#: PR#: Program EI me : 7 r7 LL3 d 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#: 1 Total Capacity: gallons Product Type: S (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Ca acit Product Type: p y: 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: ❑ Tank (2820) ElContainers (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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: '7S0 gallons,i; Total Capacity for Site: J-0 gallons Comments: { Zg -- // a EHD Inspector: Reviewed Date: Entered Date: By initial: �,�. By Initial: / 9 "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more 6f petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 , 33 AST SURVEY FORM 09!12!08 ii