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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: Page --L of Facility Address: City: Inspection a a S Ani I G-� eJ �v�' 5,C q/,0 rJ /l/ t7: J� FA#: PR#: Program Element: T ® _ Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks' and containers". � Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1Product Type: J�l�sl Total Capacity: S a-0 gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) lJ Containers (2821) #of Containers: L_ T-An#,: 2 Product Type: Total Capacity: '� gallons f� n (per tank or cumulative for containers by product type) Install Date: 7._�/�/Pr47J l.VA r1"�Bp-1 ❑ Tank (2820) Q'Containers (2821) #of Containers: TA#: 3 , Product Type: /Ll Tot pr U - Total Capacity: // b gallons (per tank or cumulative for containers by product type) Install Date: _ ElQ Tank (2820) "Containers (2821)' #af Containers: I TA#: j 4 .. �/�17n k ce �Cy Total Capacity: .� � gallons Product Type: LG (per tank or cumulative for containers by product type) Install Date: ,_�P'C._ #of Containers: Y TA#: ❑ Tank (2820} Iontainers (2821} i } 5 Total Capacity: //0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: r) gallonsTotal Capacity for Site: gallons F" Comments: f G� 'r EHD Inspector: Reviewed + - J Date: i Entered Date: ✓ a Byinitial: �1Al� I -� By Initial: �L I 0 "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