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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: �Z7/ Cl Page 1—/ of i�9 MJ/j/ ity Facility Address:� C -�i%'' / 313 a - L a Insion D e: 7,34 p FA #: %jJ PR M 1 db,:,? ?e Program Elemen : -2- Tank/Container 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) ❑ Containers (2821) #of Containers: TA#: At O 1Product Total Capacity: d t> gallons Type: yp ro (per tank or cumulative for containers by product type) Install Date: Ly' Tank (2820) ❑ Containers (2821) #of Containers: TA#: 6-1 'z-�Z_ l 2 Total Capacity: �� gallons Product Type: _;�j%E/ %%� r✓ ©% (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: H 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