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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: l _ SL C3 S�jL Page of Facility Address: City: Ins action Date: Z N LY, � c�GL� i IE d FA#: O PR#: Program Element: 2 63 1 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#: D,S-) 1 Total Capacity: p0 Product Type: . N1 C��(_ tZQ� y� p y: gallons (per tank orcumulative toropnlarners by producttype) Install Date: .. ONY M&N Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5-19,610 2 Total Capacity: D�() gallons Product Type: i� L (per tank or cumulative for w tainers by Droduct type) Install Date: CIN (KA iI Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: t (D" gallons Product Type: .. (per tank or cumulativefor containers by product type) Install Date: li Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: l [3>)/� gallons Product Type: �F2 (per tank or cumulative for cont oars by product type) Install Date: U 1 V[L Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Q jesf-L Total Capacity: I ! ()&b gallons (per tank o(cumulative for containers by product type) Install Date: ()N k---,- Total Capacity this Page: gallonsTotal Capacity for Site: gallons Comments: EHD 1 actor: Reviewed Date: Entered Date:/ By Initial: (.t 1-t p By Initial: d *AbovegroUlid 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