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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 Nam 0 S7 Page of w Facility Address: City: i r s-t I 19 1>J Z nspe 6 FA#: r t? -z' PR#: � O Program lemeQt: I A rz- Tank/Container Information �TGiF/J Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: :TA Total Capacity: gallons ' (per tank or cumulative for containers by product type)00" Install Date: I I Tank (2820) 0 Containers (2821) #of Containers: � TA#: 2 �-._-.__..-._. Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TA#: F 3 Total Capacity: gallons Product Type: i (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ElContainers (2821) #af 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#: I - . 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: j_ Total Capacity this Page: gallons Total Capacity for Site: + gallons ` Comments: " dS 03 3 " 5 tlwcoaplc-�-1 EHD Inspector: /p Reviewed Date: Entered Date: if[ fir By initial: 01•�- By Initial: "Aboveground storage tank means a tank that has the capacity to store 55 gallons or morg of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08_ i l