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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: 4�+ /� rlL �zvn� 2 +�� SSr Y / ln� Page _L__ of Facility Address: v City: Inspectio Dat 0 Q $ �� S0vT,� A n119 FA M. PR#: w Program Element: 05 0� 4[ 0 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks* and containers*". Complete one box for each tank or each cumulative container product type. Tank(2820) ❑ #of Containers: TA#:Containers (2821) 1 Product Type: Total Capacity: . 'Z1 (2 gallons (per tank or cumulative for containers by product type) Install Date: a. ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (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: ❑ 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: If gallons Total Capacity for Site: gallons Comments: EHD Inspector: - Reviewed Date: Entered Date: By Initial: By Initial: j! '"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 26-01 AST SURVEY FORM 09/12/08