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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: C.Lt03 L Pageof 3 Facility Addres^sC 3 �: 'ty v r C ' In/spe tion Do e: FA M _( PR v: c, ` td Program Element: (� a 2 �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 roduct type. 7(pertank 0) Containers (2821) #of Containers: TA#: Product Type: t`A_)hA/xC rti T�-4 MPt C/ UJtn Y _gallons �h ative for containers by product type) Install Date: ❑ Tank (2820) X Containers (2821) #of Containers: I ? TA#: 2 Total Capacity: �S gallons Product Type: Wk-/ b r -U l/C Gwf h (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ,Containers (2821) #of Containers: TA#: 3 Total Capacity: [6 gallons Product Type: 0D 1O(n b1Z. (per tank 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Ins or: Reviewed Date: Entered Date: UA rljA� By Initial: By Initial: �p O *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. 1 **Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM