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SAN JOAQUIN COUNTY ,. 'ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 t Telephone:(209)468-3420 Fax: (209) 468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Na "e: - 'd _ 0 -r A A/A Page / of �+ Facility AddKress: r f�T1f I/I/ City: Inspection Date: 1 41 FA C PR M Program Element: l S 1 D6�3o TanklContainer Information Complete for all sites with cumulative aboveground storage of petroleum al,320 gallons in tanks"and containers". J Complete one box for each tank or each cumulative container eroduct type. ank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: �r ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 ` Product Type: >� .r _.__ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) [� Containers (2821) #of Containers: �_ TA#: ,r 3 Product Type: /o*"P Total, Capacity: gallons (per tank or cumulative for containers by product type) Install Date: I I - ❑ Tank (2820) UContainers (2821) #of Containers: TA#: 4' : Product Type: PAO C'/C2` 0� U Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: k #of Containers: TA#: El Tank (2820) Containers (2821) 5 l Product Type: Total Capacity: ji gallons (per tank or cumulative for containers by product type) Install Date: } Total Capacity this Page:/rI gallons Total Capacity for Site: ✓ gallons Comment's: , 11 - _ -IDA V),S i EHD inspector: `. Reviewed Date: Entered Date: sy Initial: �,��.� 8y Initial: P19 ?/vir 99 "Abovdground 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. END 28-01 AST SURVEY FORM 09/12/08