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00 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: I r N L Page of Facility Address:�� f? City: Inspecti n Date: _^ U 2/ FA #: PR M Program Element: 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: #: 195I 01,�9 1 Total Capacity: gallons Product Type: ( r tank or cumulative for containers by product type) Install Date: 2%�. Tank (2820) ❑ Containers (2821) #of Containers: TA#: Total Capacity: �� gallons Product Type: W(g 4PL (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: SSI �� 7& n 3 30 Product Type: �✓% Total Capacity: gallons (per tank cumulative for contairffrs by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers:_is TA L6-219 77 A S g 4 Total Capacity: gallons ProductType:. yp (per tank or cumulative for contain rs by product type) --. Install Date: ❑ Tank (2820) keContainers (2821) #of Containers: TA#: O 5gallons Total Capacity: Z Product Type:�� (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: S gallons Total Capacity for Site: 21 gallons Comments: '* 2 % / o N A/ 17 //I S F j T.f�L e��yr� 1vou Gn /� /i C" -/Ow s7vlri"F" l -- dlv� AZQ &2TOS EHD Inspector: Reviewed By Initial: Date: 45 �'� Entered Date: By Initial: g o2 *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