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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 Name: Page of Facility Address: City: Inspection D te: C-gOJ4/9/7s- 77"a ,BIKW. �7 a 'x/14- is FA#: �Y�—/ PR#0� /� Program Element: Z 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. Q Tank (2820) El Containers (2821) #of Containers: _ TA#:: �h 19/v�� 1Product Type: J Total pacity: /�� gallons 0/1 *pr Co rcumulative for containers byproduct type) Install Date: _t M Tank (2820) ❑ Containers (2821) #of Containers: TA#: DS/ Co2S 2 Product Type Total Capacity: �a gallons .� (per for cumulative for co tainers 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 1Q gallons Total Capacity for Site:�Q� 12�j gallons Comments:) �l� L Cy � l 0,1;y rt _� -t v rf 1 C �rT ✓1 .. EHDlnspe ReviewedVV•' Date: Entered - Date: By Initial: 5 •LN•id 8y Initial: *Abovefrou/r,tr storage tank means a tank that has the capacity to store 55 gallons or more of petroleu . "ContaInat means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM