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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: AE /(LC r" (I(7U I Page a of FacilityAddress: ,yb t7 j Cit Ins echo Da e• 2 � 7 l S Al, JS �0 � y a,_ rye J d7 FA#: / PR#: Program Element: DO t AlllP B5ag0ee 7, 830 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. Tank (2820) El Containers (2821)Total Capacity: #of Containers: TA#: D51 7 / Er 1 r D / gallons Product Type: �,t'buL � (per tank or cumulative for containers by product type) Install Date: P Tank (2820) ❑ Containers (2821) #of Containers: TSA#: h)-7 :z / 3 2gallons Product Type: X01 7�X Total Capacity: r 6' C (per tank or cumulative for containers by product type) Install Date: L'1 Tank (2820) ❑ Containers (2821) #of Containers: / TA#: 19 5) 771 3 Product Type: Total Capacity: / c0 0 0gallons (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 Page: /7o Q i) gallons Total Capacity for Site: gallons Comments: EHD Inspector: t Reviewed Date: Entered Date: By Initial: By Initial: / `pt, 3 *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