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SAN JOAQUIN COUNTY *lWW 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 _ rL Page Of Facility Address: city: C% !V 7 O / Inspe tion 2 T It : Z S o1361gTS FA#: PR M Program Element: / 0 1 R,6-30 -g 2S3d 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. W�fank (2820) El Containers (2821) #of Containers: TA#: LE�c 1 t? 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Ink (2820) ❑ Containers (2821) #of Containers: TA#: _ 2 Product Type: (pert Capacity: gallons (per tank or cumulative for containers by product type) Install Date: *A Tank (2820) 11 Containers (2821) #of Containers: p��"' 3 Total Capacity: �gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 9-Containers (2821) #of Containers: TA#: 4 Total Capacity: 5,5 gallons Product Type: e!l; (per lank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Uazcontainers (2821) #of Containers: TA#: p 5 �s Product Type: W f �� D �!� d� Total Capacity: gallons —� (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page:• Z61 gallons T901 Capacity for Site: Z gallons Comments: L S D EHD Inspector: rp Reviewed \ ` �,` Date:n �(� Entered Date: (� By Initial: JA "l, - 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