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SAN JOAQUIN COUNTY J ' ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAMISURVEY FORM Facility Name: ' -j—CT S�n�CrV/ff I✓ TTj f=AM �y 61 Page ./--of L_ Facility Address: City: Inspectic ate� Zgme ' 6! '] S6 ��IZ/�I/f✓ 'D // // FA#: / r / 1 � PR#: � � Program F eT v. 17 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum a1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. VTank (2820) El Containers (2821) #of Containers: TA#: 1 Total Capacity: w Op —gallons Product Type: (per tank or cumulative for containers by product type) Install Date: /Tank (2820) ❑ Containers (2821) #of Containers: TA#: ? Total Capacity: D gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) F-1Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons ` (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 ©ate: Total Capacity this Page: Q gallons Total Capacity for Site: gallons Comments: ' LV 'C v a E EHD Inspector: Reviewed Date: Entered Date: r By Initial: �`�C6• By Initial: *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 09/12108