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1 71 SAN JOAQUIN COUNTY T. " YNVIRONMENTAL 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: A )J C 0 7-14 Page—�— of L_ Facility Address: 8 r�rsco�7 city: Inspec Ion Date, � FA#: PR#: Prog!fia Elearu Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers"x. Complete one box for each tank or each cumulative container product ty2e. #of Containers: vlank (2820) El Containers (2821) _� T #: 1 Total Capacity: gallons Product Type: 12 (per tank or cumulative for containers by product types Install Date: q/ank (2820)' ❑ Containers (2821) #of Containers: TA#: 2Product Type: S Total Capacity: 00 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank 2820) E91/container's 2821 #of Containers: - J TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for con1alne7s 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: 13 Tank (2820) ElContainers (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: 174 gallons Total Capacity for Site: i gallons Comments: p C-a ,F- o S Z2 On EHD Inspector: Reviewed Date: Entered Date: By Initial: r � 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 09112/08