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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:p f 9C.1 �(L '5 Lue'-'\6 L Page Z of Facility Address: City: Inspe tion Date: O Z ��, Shic, (04xj ,r' Zcr%e7 FA#: PR M Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) Xcontainers (2821) #of Containers: I7 TA#: /9,SlS q� f 1 g Product Type: t4V'4r�, 1/c, 01 Total Capacity: gallons (pertank orcumulative for containers by producttype) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: Z TA#: 2 Total Capacity: l ( t) gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (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: Z 3�O gallons Comments: EHD Inspector: ( r Reviewed Date: Entered Date: V By Initial: By Initial: *Aboveground stordige 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