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#: SAN JOAQUIIN COUNTY �Wj ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd J 41BOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM �i Facility Name: Page —L of he�,E= 37- ryzV IV Q l Facility Address: City: Inspectio 77c) 3' G✓ 7i FA#: PR M Prog ard Element: 2 g Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2:1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product tyee. ank (2820) ElContainers (2821) #o#Containers: TA#: 1 - --- Product Type: Total Capacity: S'�' gallons (per tank or cumulative for containers by product type) Install Date: WT:ank (2820) 11 Containers (2821) #of Containers: TA#: 2 Total Capacity: -Z—A—V gallons Product Type: T (per tank or cumulative for containers by product type) Install Date: C7 Tank (2820) ❑ Containers (2821) #of 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: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: ❑ Tank (2820) ❑ Containers (2821} , 5 /f Product Type: Total Capacity: i gallons (per tank or cumulative for containers by product type) Install Date: i / Total Capacity this Page: gallons Total Capacity for Site: gallons Comment's: I i I t EHD Inspector. Reviewed c Date: Entered Date: 'By Initial: VIA �` Cc, tBy Initial: � t *AboveIground storage tank means a tank that has-the capacity to store 55 gallons or more of petroleum. I "•Container means a storage device designed to be moved when full.. 9 EHD 28-01 ii AST SURVEY FORM 09/12/08