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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: S1Q i? L Q D �LICIG�IO/e Z)IC' . Page 2 of 2 Facility Address: City: Ins con Da FAa: �� S• Hu� PR#' Program Element: dr'Rp 26_ 3 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: Z TA#: 1 Total Capacity: �-?5 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAI 3 Product Type: Total Capacity: gallons (per lank 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 Product Type: Total Capacity: gallons yp ' (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 1�2 1:3 gallons Total Capacity for Site: (r-, gallons Comments: EHD Ins ctor: Reviewed Date: Entered Date: By Initial: i �sE'a'I� � ) 9 6 i By Initial: e / "Abo gr Ind storage tank m s a tank that has the capacity to store 55 gallons or more of petroleum. '"Co mer means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM