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• SAN JOAQUIN COUNTY 0 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: . Page l of /I A c'� 9 Facility Address: _ _ City: Inspec7inDat ? / �� , Iii ✓`�'� �) 1 FA#: PR#: Program EI ent: 9-10 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. o Tank (2820) ❑ Containers (2821) #of Containers: TA#: 17 7!6_7 1 - � Product Type: Total Capacity: �' gallons (per tank or cumulative for containers by product type) Install Date: •� t� © Tank (2820) El Containers (2821) #of Containers: TA#: d 6—/7 7,j5'5' 2 i�! ;%' Product Type: >� �r, Total Capacity: / z gallons (per tank or cumulative for containers by product type) Install Date : � D Tank (2820) El Containers (2821) #of Containers: TA#: /96-1 -176_2 3 Product Type: ✓4 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (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: (_J Ci gallons rTotal Capacity for Site: a1 (r ) gallons Comments: EHD Inspector: Reviewed W Date: Entered Date: By Initial: iy-uC� 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 28-01 AST SURVEY FORM 09/12/08