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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: �7 / j gor Page _ of Facility Address: ^ n / City; Inspection Da22 tR� FA#: O( PR#:K//G,l/ Program Element: 2,6o aZ $ d et?13 a, 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#: 0.,ql /p) 1 Total Capacity: , (X gallons Product Typbl (per tank or cumulative for containers by product type) Install Date: o Tank (2820) ElContainers (2821) #of Containers: TA#: S6-1 6t to 1 2 Total Capacity: �Wgallons Product Type: (per tank or cumulative for containers by product type) Q G Install Date: / Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: Idloho gallons Product Type: (per tank or cumulative for containers by product type) :1 Install Date: v� V Tank (2820) ❑l Containers (2821) #of Containers: TA#: 4,;—L� 4 Total Capacity: 0 60 gallons Product Type: (per lank or cumulative for contains by product type) Install Date: I"1A Ile Tank (2820) ❑ Containers (2821) #of : �� TA#: 5 Product Type: 02 X t30, llo0rl D I� Total Capacity: gallons (per tank orcumulative for contai ersbyproducttype) Install Date: Total Capacity this Page: ()d D gallons Total Capacity for Site: gallons Comments: :xl oDo � S EHD InsRgoor, Reviewed Date: Entered Date: By Initial: I,Xvii.10 By Initial: a y `Ab round storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. o� "Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY DORM