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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: R0 C A0. �- ^G-1?/?0Page 1. of Facility Address: City: Inspection'D ate- FA C PR W Program Element! Tank/Container information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers". Com tete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821 #of Containers: TA#: '} 1 Product Type: Total Capacity: t9-{) .. gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: E= El Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: . (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers:. TA#: Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 11 Tank (2820) E3Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: i (per tank or cumulative for containers by product type) Install Date: - 1 It Total Capacity this Page: - gallons Total Capacity for Site: 3 gallons Comments: i EHD Inspector: Reviewed Date: 'l Entered Date: r_1 IBy initial: 4-tq-& By Initial0 k{ *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