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` y 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:} Il.ta1l� 13�7 �6m1 �� Page of I k061 ?Oa o Facility Address: City: Inspection ate: i FA #: % PR #: 79 Program EI mec;t� '2- 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) ElContainers (2821) #of Containers: TA#: 1 Total Capacity: 2b 000gallons Product Type: (per tank or cumulative for containers by product type) Install Date: EA'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 .� Total Capacity: I �' �'- % gallons Product Type: i O (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: 3 (? 0Product Total Capacity: / 0 gallons Type: (per tank or cumulative for containers by product type) Install Date: f ❑ 'Tank (2820) ❑ Containers (2821) #of Containers: TA#: eSIg 4 �- � 6 <j gallons Total Capacity: Product Type: �i—/'' S �� . (per tank or cumulative for containers by product type) Install Date: i 1:1 Tank(2820) eContainers (2821) #of Containers: TA##: 6� I $ra©q 5 Total Capacity: O gallons Q� Product Type-.'--,- ype: (per (per tank or cumulative for co tainers by product type) Install Date: Total Capacity this P, 7 `'z- `GI 4 gallons Total Capacity for Site: ® gallons Comments: EHD Inspector: Reviewed Date: By Initial: Entered By Initial: Date: '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