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x +y, SAN JOAQUIi i 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: d - !:� .2 'Page —L of G / > Facility Address: City: lnspectl :iDab FA#: PR#: (Program ment: 19 17'6'1(-D Tank/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. Tank (2820) ❑ Containers (2821) #of Containers: TA#. 1 Total Capacity: �Ot gallons Product Type: (per tank or cumulative forcontainers by product type) i Install Date: Tank (2820) ElContainers (28' 21) #of Containers: TA#: 2ailons Product Type: �.. Total Capacity: J g (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: a 3Total Capacity: Z- d d gallons Product Type: (per tank or cumulative for containers by product type) Install.Date: ❑ Tank 2820 Q'Containers 2821 *of Containers: I TA#: ( ) ( } f 4 Total Capacity: S gallons Product Type: hill (per tank or cumulative for containers by product type) Install Date: t s ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install,Date: Total Capacity this Page: £gallons .Total Capacity for Site: 00-C gallons Comments: 't EHD Inspector: ,Q Reviewed Date: Entered Date: (— By Initial: kxtj . y-l�f-00k By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum..-". a "*Container means a storage device designed to be moved when full. { EHD 28-01 ` AST SURVEY FORM 09112Io8 E. I ,