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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name- n r aA a IV C' h �� Page of Facility Address: City: Inspec ion Oat V /sff FA#: PR M Pr gram 1 t: J � a 0592g 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 e. Tank (2820) ElContainers (2821) #°f Containers: LA#: 1 Total Capacity: gallons Product Type: a. 0,2P02 (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: � ❑ Tank (2820) ❑ Containers (2821 ) 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: t (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: a- ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 8 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: rl'TJ gallons Total Capacity for site: gallons Comments: 4 Y EHD Inspector: Reviewed Date: Entered Date: By Initial: Cj•�- 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 09/12108