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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:FaS�U tip Page _ of `1 Adtl{e�s; G S G �y� 6 Inspec on Dat Program Element: 6 3IJ � 2C(i31 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#: i�9p�rjp9r,Qy x 1 Product T �,V � Total Capacity: B dons Type: —h t (per tank or cumulative for containers by product Type) Install Date: U"IJ Tank (2820) ❑ Containers (2821) #of Containers: Tq#,e B _/ 2 Total Capacity:acit 25 Product Type: �A/ c� 1 13 . _gallons �� (per tank or cumulative for containers by product type) Install Date: ULCn,,� Tank (2820) :.nmmers ntainers (282 1) #of Containers: TA#: 3 Total Capacity: _ / gallons Product Type: bV ElS�2 9/JIUG/L (per tank or cumulative foby protluct type) Install Date: U N A ll Tank (2820) ❑ Containers (2821) #of Containers: TA#: j2.,5—) 4 Total Capacity: _ gallons Product Type: Qll M, f �n (per tank or cumulative for containers by product type) / n t V-_ �1l Install Date: SIV N-��'t/� Tank (2820) ❑ Containers (2821) #of Containers: TA#: �66�) j 5 Total Capacity: j 5 gallons Product Type: r A-r.,"(per tank or cumulative for containers by product type) Install Date: UpUTotal Capacity this Page: -7J5TOgallons Total Capacity for site:Comments: a7� sau EHD Inspect 6, / V� -Reviewed Date: Entered Date: By Initial: By Initial: / /f 10 *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 09/12/08 AST SURVEY FORM