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{ z SAN JOAQUIN COUNTY .. ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s}gov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: hfN J j2 Page of Facility Address., r _ -,; City: InspW: - Tank/Container i 3 y � .-. �L -•FA#: PR#: rog1 Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks"and containers". � Com fete one box for each tank or each cumulative container roduct t e. U Tank (2820) ❑ Containers_ (2821) #of Containers: -TA#: 1 Total Capacity: Qo gallons Product Type: -- •-• .-- (per tank or cumulative for containers by product type) Install Date: 10ank (2820) Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: t L/ (per tank or cumuiative for coainers by product type) Install Date: .E C1 Tank (2820) Containers (2821) #af 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: Y TA#: 4 Total Capacity: /1 Z) gallons Product Type: s— (per tank or cumulative for containers by product type) Install Date: r ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 8 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 'total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: 'Ifp. QQ` 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 08112/08 �M.