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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: {- �O Page of Facility Address: City: / 6 0 r-- c.T� Inspecti n a 7 2 FA #: PR M Program, Element. f 12 3VTank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks` and containers". Complete one box for each tank or each cumulative container product type. LQ Tank (2820) El Containers (2821) #of Containers: TiA#: /9,5-1211-72 1 Product Type: Total Capacity: a 0 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: g 2 r' Product Type: Total Capacity: G'Y) gallons (per tank or cumulative for containers by product type) Install Date: 19 Tank (2820) El Containers (2821) #of Containers: TA#: 6�� Z-2 c 3 Product Type: �� Total Capacity: gallons (per tank or cumulative for container by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 19 I'L S- 7 4 V, 60 Product Type: _z/'� - C Z' Total Capacity: gallons (per tank or cumulative for containeTsby product type) Install Date: Tank (2820) ❑ r-r-l'iners (2821) #of Containers: TA If 5Product Type: Total Capacity: _gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z !'c) -o gallons Total Capacity for Site: gallons Comments: [' EHD Inspector: i Reviewed Date: By Initial: V\A 01 Entered Date: 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