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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: r /I 1, 1 "D �19IVT r� Page of Facility Addres J CInspect' n Date:B FA#: PR#: Program Element: / gyp D --'z 3 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. ank (2820) ❑ Containers (2821) #of Containers: TA_ #: 1 g Product Type: -Zef Total Capacity: Erp gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) 2-containers (2821) #of Containers: TA#: 2 / Product Type: LJ DTP/Y Total Capacity: 6 S gallons / (per tank or cumulative for containers by product type) Install Date: El Tank (2820) TJ Containers (2821) #of Containers: TA#: 3 140 Product Type: Total Capacity: 1Lrir4ST� O� �' 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: (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 Pap, gallons Total Capacity for Sit. gallons Comments: C 13 ZOA N IIS EHD Inspector ,/ Reviewed Date: �; Entered Date: J By Initial: �r_n W 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