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I 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 ., ,I Facility Dame: 1 L o Page Of ! Facility Address: U j L , FF A r► Y .,C Its (G Inspect{ ate: kv FA#: PR#: Probrainn.EI men : i / 7 ,/- 67 -Z 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. VTank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: z 0 gallons Product Type: Uk (per tank or cumulative for containers by product type) install Date: 'Containers 2821 #of Containers: 1 T TAM Elt�d Tank (2820) ( ) 2Product Type: JT " �! Total Capacity: � gallons i AZQ (per tank or cumulative for containers by product type) Install Date: a f ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: _ ^ (per tank or cumulative for containers by product type) Install Date: i ElTank (2820) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: V El Tank (2820) ElContainers (2821) #of Containers: TA#: I 5 Total Capacity: gallons Product Type (per tank or cumulative for containers by product type) Install Date: gallons Total Capacity for Site: gallons Total Capacity this Page: 3 d S Comments: EHD Inspector: Reviewed Date: Entered Date: By initial: a,2��0 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 28-91 I. AST SURVEY FORM L . os/l2Joa I