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SAN JOAQUIN COUNTY e 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 Name: D S Page of Facility Address: City: Inspection Date: 1= dt'vy v .t6-0. FA � �/ � PR#: � Program Element: 2 g r7� Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. ank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: ,rn (per tank or cumulative for containers by product type) Install Date: .E1Tank (2820) ontainers (2821) #of Containers: TA#: 2 Product Type: _ Total Capacity: gallons (per tank or cumulative for con iners by product type) Install Date: ❑ 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: ;❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page:, gallons 'Total Capacity for Site: 70- gallons Comments: EHD Inspector: Reviewed Date: Entered Date: / By initial: c6,i'`.0� 8y 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 28-01 AST SURVEY FORM 09/12/08