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SAN JOAQUIN COUNTY '` ,, LdENVIRONMENTAL HEALTH DEPARTMEN 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: z 11116 1-L'I *ag of Facility Address: Cit n Date: A uE �s �FA#: PR#: El en: Tank/Container Information Complete For all sites with cumulative aboveground storage of petroleum .1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers { 821) #of Containers: TAM ZdD � ' 1 � fo Product Type: Total Capacity: allo s -- - g (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) &?Containers {2821) #of Containers: „L_ TA#: o 2 Total Capacity: gallons Product Type: /U (per tank or cumulative for containers byproduct 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: - 11 Tank (2820) ElContainers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: d' --•• „ ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Tota! Capacity: gallons Product Type. {per tank or cumulative for containers by product type} Install Dat@: Total Capacity this Page: 3 f s gallons Total Capacity for Site: ® gallons Comments: N r EHD Inspector: Reviewed Date: Entered Date: c By Initial: l��Q By initial: J *Aboveground storage tank means a tank that hasthe capacity to store 55 gallons or more of pettmieum �[ **Container means a storage device designed to be moved when full., U(/ .�/1,'/f X9 EHD 28-01 _ AST SURVEY FORM 09/12/08 Y