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SAN JOAQUIN COUNTY E=NVIRONMENTAL 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: / C1 r l j � AV Page of Facility Address. r _ City: Inspectio - /l Date�/ � U/-.- % iD//'✓� �.�i -7A'-114V FA#: PR M Program�Ie'7n� y 4 ©53© 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. E Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1$q J,�!l 1 Product Type: Total Capacity: /G G �� gallons --�— (per tank or cumulative for containers by product type) Install Date: Q ank (2820) ElContainers (2821) #of Containers: TA#: _f��'► '�} 2Product Type: Total Capacity: J S � gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 19 3 -- Product Type: Total Capacity: � t�--fl gallons (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 or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 95'.5-0 gallons Total Capacity for Site: j'r o gallons Comments: EHD Inspector: Reviewed Date: Entered ate: By Initial: By Initial: "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more o petro eum. "`Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08