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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: lil �� Paged of Facility Address: City: Inspectio Date: FA #; PR #: Program Element: /,P-�� --I- , 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) 19/containers (2821) #of Containers: TA#: jq 7 1 e: Total Capacity: 400 gallons Product Type: �� (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) B"Containers (2821) #of Containers: J TA#: 2 Total Ca acity: '�!->O O gallons 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: ❑ Tank (2820) ❑ Containers (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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: I? O gallons Total Capacity for Site: �( 7Gf �J gallons Comments: Ylf- Ft H SInv%S17G� EHD Ins ctor: Reviewed Date: Entered Date: I By Initial: By Initial: / ! *Ahn pnrdi rl ctnronc +—L- . — +--i, i� „uFp Uy ,U awiC w ydnUns or more OT petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM