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k SAN JOAQUIN COUNTY V ' INVIRONMENTAL 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: 4 ie, �W1V Page of f Facility Address: 'ttU{ wq),\` Clty: Inspection Date, FA#: (] PR�[�IVU - fzrogram Ele. t: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons_j- nd containers`*. Complete one box for each tank or each cumulative container product type. ,Tank (2820) ❑ Containers (2821) #of Containers: TA#: K 1 Total Capacity: Product Type: gallons (per tank or cumulative for containers by product type) Install"Date: lit'Tank (2824) ❑ Containers (2821) #of Containers: ` TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: [ Tank (2820) 11Containers (2821) #of Containers: 11 TA#: Total Capacity: S_SD gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) " ❑ Containers (2821) #of Containers: 1`TA#: 4 Total Capacity: S1 gallons Product Type: �I (per tank or cumulative for containers by product type) "Install Date: ❑ Tank (2820) Containers (2821) #of Containers: { TA#: 5 rffliqProduct Type: (�i 1 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: �I HAA APi G I GtAI� 04/ OkweftrdA, i h5 Ave t x&4 �- 3- EHD inspector. Reviewed Date: Entered Date: a By Initial: CN•V�• l 0 8y Initial: I *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. 09112108 dt AST SURVEY FORM[ 4.