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t SAN'JOAQUIN COUNTY - " ENVIRONMENTAL HEALTH DEPARTMENT 600 l=ast Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE'PROGRAM SURVEY FORM Facility Nam P T '9 6-T C, Page--/— of Facility Address: City: Inspection Dat FA M. PR#: Program Ele ent� Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum x9,320 gallons in tanks`and containers", Complete one box for,each tank or each cumulative container product tyee. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: gallons � ••• (per tank or cumulative for conta ners by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers:. TA#: 2 Total Capacity: 7 Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (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#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) 11Containers (2821) #of Containers:' TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: �'�w gallons Total Capacity for Site: gallons Comments: a EHD Inspector: Reviewed Date: Entered Date/. to A-7 By Initial: By Initial: 7 pC *Abovegroun 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 09/1 2/08 + f �_