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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: {� I t 1a.3 �° 0 j�-A D2 M 1 N(i- CeNpPriy Page of Facility Addres _n n n „ City: InspI n D �:� FA#. 3 'Ufil< PR 0: e(,,�1 J, Program Element;, 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. rank (2820) ❑ Containers (2821) #of Containers: t� TA#:0 1rr.�ly, Product Type: Total Capacity: � gallons (pertank orcumulative for containers by producttype) Install Date: ank (2820) ❑ Containers (2821) #of Containers: / TA#: n /A1C T X Total Capacity: QY�:) gallons (per tank or cumulative for containers by product type) Install Date: I El Tank (2820) 2-Containers (2821) #of Containers: / TA#: 3 Total Capacity: �gallons Product Type: 1if/�( .S l 0r (per tank or cumulative for containers yproduct type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank orcumulative 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: (� j� gallons Total Capacity for Site: /0 gallons Comments: EHD Inspector. Reviewed Date: !� Entered Date: By Initial: � -5-0 1 By Initial: CZ)l D `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 09/12108