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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.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Na 'A'q r'(g s C qq ^ to G y Page —L— Of Facility Address: J/ J`--ity:s Inspecti n Dat 9 z-s - l 90 /+f i ova ,S�oRN710 I �d FA#: PR#:&95WE Pro�r� menu CJ L• 7? 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. [B Tank (28?m n rnnfniners (2821) #of Containers: TA#: D,ri / 'j53oZ 1 Total Capacity: -30�- Of1C-)� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TAS#J: fl,h ) 75-3 2t Capacity: 2-0j �©`) gallons Product Type: (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: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank orcumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 570,, 020 gallons Total Capacity for Site: 5 J 0 00 gallons Comments: EHD Inspector: Reviewed Date: Entered t Date: / By Initial: 1�.�,J� By 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. EHD 28-01 AST SURVEY FORM 09/12/08