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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: T d C o �/ - r , T4 1, O � �� j Page _.L__ of Facility Address: -r City: r F1� Ins t. / ZO id, LIQ` ' FA #: r PR M �5a 15 8 a3 Program Ele rry _Z 31 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) El Containers (2821) #of Containers: TA#: �9e�i�'J 1Total O�C� Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Lel Tank F-1Containers(2821) #of Containers: TA#: (2820) 2 Total Capacity: gallons tank Product Type: lqs— (per or cumulative for cMTainers by product type) Install Date: mr ElContainers #of Containers: TAS #: Tank (2820) (2821) 3 Total Capacity: � 0-0 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: ❑ Tank (2820) ❑ Containers (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: ZQ 0,69 gallons Total Capacity for Site: gallons Comments: CV RNA ihAD say► �- o�� EHD Inspector:t� Reviewed Date: By Initial: �Al" 1 Q:N - 0*/1 Entered Date: By Initial: 3i *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