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1 Ns, SAN JOAQUIN COUNTY NVIRONMENTAL 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: r tV L6R C Page . of�— Facility Address: City: 'Inspection ate: FA#: 17373 7373 PR#: Progra�e 5 ' T-'i Tank/Container Information Complete for all sites with cumulative aboveground storage of,petroleum 2-1,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container product type. EP/Tank (2820) ElContainers (2821) #af Containers: TA#: 1 �-- Product Type: YJ Total Capacity: 3; O _ gallons --- (per tank or cumulative for containers by product type) �' Install Date: V],�a nk (2820) ElContainers (2821) #of Containers: TA#: 2Product Type: Tota! Capacity: 3L� gallons - -- (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: - �J gallons Product Type: (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: gallons Comments: EHD Inspector: r9 Reviewed Date: Entered Date: G C By Initial: By Initial: "'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 moved when full; EHD 28-01 AST SURVEY FORM 09/12/08