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S SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 least 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 Nam ei � � � � Page of Facility Address: City: inspect'En Date: FA#: PR M Progralement: d�. Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks*and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9A 112ze / 1 Product Type: eo L Total Capacity: 1006 gallons (per tank or cumulative for dontainers by product type) Install Date: Tanis (2820)• ❑ Containers (2821) #of Containers: TA#: � GAS,) (fes. 2 Product Type: Total Capacity: ��(��_gallons . (per tank or cumulative for containers by product type) Install Date: it Tank (2820) ',Containers (2821) #of Containers: 3 Product Type: ` Total Capacity: gallons (per tank or cumulative for tainers by product type) Install Date: ' '❑ Tank (2820) $Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for cchfaiinereby 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: O gallons Comments: EHp inspector: Reviewed Date: Entered Date: ON 8y Initial: By Initial: &[I( ' )P? *Abbv—egr-ounk 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 09112/08