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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: ,). /' _ / �1 f� f� C C_' r7 � l I f ,'% L V fN y Page of Facility Address: p City: / Inspectio Date: lq FA#: PR#: Program ElPmo�• n Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks* and containers", A Complete one box for each tank or each cumulative container product type. Tank (2820) El Containers (2821) #of Containers: TA#: D6-1�� 1 / , Product Type: a Total Capacity: / O r') 1 gallons (per tank or cumulative for containers by product type) Install Date: �nk (2820) ❑ Containers (2821) #of Containers: TA#: 1 2 /! (0Product Type: Total Capacity: � � gallons (per tank or cumulative for containers by product type) Install Date: ri�'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 06)tf�oZ 3C- Product Type: Total Capacity: J i�` gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: � D j�r� ��L �� (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Containers (2821) #of Containers: TA#: g 5Total Capacity: � gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed � ^I Date: Entered ) t Date: - By Initial: �v lo.01 By Initial: *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