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` 8 SAN JOAQUIN COUNTY it 1 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 Nar is a OL3EMA Page --L— of Facility Add ass: City: Inspec i n Dat HL, 130 FA#: PR#: Program EleInd o o � 0 3rd -2, 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) 1:1 Containers (2821) #of Containers: TAr g 1 Product Type: J1 Total Capacity: A 0-0gallons (per tank or cumulative for containers byproduct type) Install Date: Ty ES/Tank (2820) ❑ Containers (2821) #of Containers: -T 0514�RSd 2 Product Type: yj-le � Total Capacity: _gallons (per tank or cumulative far containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: �� (per tank or cumulative for confainers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 4Product Type: Total Capacity: f9'() gallons (per tank or cumulative for containers by product type) Install Date: �Zj 7—/5- 4 L,q�i/GT ❑ Tank (2820) ontainers (2821) #of Containers: TAM t9167R-9af- 5Product Type: /�� 412L O/ Total Capacity: gallons � r (per tank or cumulative for container by product type) Install Date: Total Capacity this Page C� gallons Total Capacity for Site: gallons Comments: *vA 6,?j voV- EHD Inspector: " Reviewed YA� Date: Entered Date: - By Initial: L6,�-(- 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