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1 SAN JOAQtJIN COUNTY l ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,:Stockton, CA 95202-3029 ?elephone:(209)468-3420 Fax:(2U9) 468-3433 Web:www.sjgov.org/ehd 1i� ABOVEGROUND PETROLEUM STORAGE :'PROGRAM SURVEY FORM Facility Name: - T Page of Facility Address: I' City: Inspection Date: r 0^eST 7Qn/ FA#: PR t!: 99-5--3 +--`r Program Element: _ Tank/Contairier 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: t TA# 11, Total Capacity: v d gallons Product Type: (per tank or cumulative for containers by product type) Inst Eall Date: 1 ❑ Tank (2820) ❑ Containers (2821) #of,Containers: TA#: 2 Product Type:. Total Capacity; gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers:. TA#:. v' 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: 11i1 . ElTank (2820) ElContainers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: t,l , #of Containers: ' TA#: I" ❑ Tank (2820) ❑ C-ontainers (2821) F 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: O 0 gallons il; Total Capacity for Site: 500 gallons Comments: dZ7.— C /� '2-0 '� Ifo -P EHD Inspector: Reviewed Date: Entered Date: I C - 6 , I By Initial: l -1y- `6 By Initial: e- a /*I li� *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 moped when full. EHD 28-01 AST SURVEY FORM a9/12 O8