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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� f ,8 Gl r 6C 5 Xpl,16 .L, -.N,�f Page Z- of . Facility Address: City: Inspe tion Date: D 2, ty S�C, 1040.1 FA#. PR#: Program Element: I ( 10 3 eon g 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) XContainers (2821) #of Containers: 7:7;1'2 TA#: 1 Total Capacity: �gallons Product Type: ��Y�r� I/C O) (pertank orcumulativefor containers byproducttype) Install Date: ❑ Tank (2820) IXContainers (2821) #of Containers: Z TA#: Q6'1g4L?A 2 Product Type: V� ) AS � Total Capacity: ��gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) *of Containers: TA#: B�e2D I Lo[r 3 Total Capacity: ; �O gallons Product Type: Co yyZ Si O n irl h i Lo i fO r (per tank or cumulative for containers by product type) Install Date: Tank (2820) EDContainers (2821) #of Containers: TA#: P75 7i9/ lo�_ 4 Product Type: 7;DI e-S F Total Capacity: �JOO gallons (per tank or cumulative for containers by product type) Install Date: X Tank (2820) ❑ Containers (2821) *of Containers: TA#: 5 Total Capacity: 500gallons Product Type: G1QS0//of (per tank or cumulative for containers by product type) Install Date: C)-)c Total Capacity this Page: r C gallons Total Capacity for Site: — o_ gallons Comments: EHD Inspector: _' Reviewed /') Date: Entered Dale:? N By Initial: t`� �1 r1 By Initial: *Aboveground stor ge 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 AST SURVEY FORM 09/12/08/08