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$ 6je 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: �7 r Page � Of G — LOD1 eGL� S�'�_ 9 FacilityA dress: City: Inspectio Da : a 'W `T V2A1gtU 1/13ta 2 FA#: PR#: Program�El em eftt:, � oJo3 O-Z Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in kanks* and containers**. Complete one box for each tank or each cumulative container product type. I Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: 11 gallons J (per tank or cumulative for containers by product type) Install Date: ' #of Containers: TA#: ❑ Tank (2820) ❑ Containers (2821) _ 2 Product Type: Total Capacity: gallons _ (per tank or cumulative for containers by product type) Install-Date: i #of Containers: TA#: r ❑ Tank (2820) ❑ Containers (2821) 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: i ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Produc#`Type: (per tank or cumulative for containers by product type) Install Date: ElTank,(2820) ElContainers (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: 2„/ n gallons Total Capacity for Site: 'Z 0 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: C" By Initial: �� 0 By Initial: �2 t *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of pe roleum. "*Container means a storage device designed to be moved when full. EHD 28-01 !3 AST SURVEY FORM 09!12!08