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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: s moi' Page _,7 of 2— Facility Address: I 220 i-F►rc-e- City: Inspection Date: ��-o�k� FA #: PIR #: Program Element: 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. AT Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: /Or... L o,' / (per tank or cumulative for containers by pr8duct type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: z9�1 q?Li r 2Product Total Capacity: Z 2�� gallons Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 91�7/2 3 Total Capacity: � 2� gallons Product Type: ( Sr —1 — L/ -Cl (per tank or cumulative for containers by product type) Install Date: EA Tank (2820) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: p y: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: L i Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0 3 r c `7 E. '2—_ 5 Total Capacity: / t i gallons Product Type. -> ✓L.>J �� ✓ � �--. f- v r l (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: S gallons Total Capacity for Site: gallons Comments: 25 %� EHD Inspe r: ��Ryviewed Date: ---TEntered Initial: Date: By Initial: 1'�- // *Akn .,.J 4__1_ - - /�✓WQIVUI 1U QrU�QyV ldIrll rr lCCI hS a UahK that nas the capacity to store bb gallons or more of petroleum. ( t **Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM