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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 { Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r rr 1 Q ltdAr-5 Page of Facility Address: Inspecti n Da 9: X 6 9 Y " / 7-v w, .* I/ FA#: I PR#: Progra m tzt e�tt� 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 - � Product Type: �/J4ZA � Total Capacity: gallons -.-- (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: Q 490 gallons . (per tank or cumulative for containers 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: ElTank (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#: 8 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: 'Zj��D gallons Comments: t >=HD Inspector: Reviewed Date: Entered Date: e By Initial: ��. By Initial: V "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. is "Container means a storage device designed to be moved when full. ; _ .z� f END 28-01 AST SURVEY FORM 09/12/08