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• 0 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: / � ICNARV 6J 0 Page —Lof� Facility Address: City: Inspectlo Date: 2 -73 8 / N �36r2ssaN, ,l/ iZ-1.� or FA#: PR M Program Element: O (L52 073 283 "1 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks"and containers". Complete one box for each tank or each cumulative container product type. /T^ank (2820) ❑ Containers (2821) #of Containers: y 6 TAS#:: 1 � p gallons Product Type: rz-A S Total Capacity: 5 (per tank or cumulative for containers by product type) Install Date: Wank (2820) ❑ Containers (2821) #of Containers: , TA#: 19, 2 Product Type: 0" " Total Capacity: (� O gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: rTA#: D,S/ 7 7 93 3 Product Type: Total Capacity: �C OPJ gallons (per tank orcumulative for containers by product type) Install Date: '/' V/Tank (2820) El Containers (2821) #of Containers: TA#: ,�J 1 7 7e2`t 4 Total Capacity: /0 a 0d gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: L} gallons Total Capacity for Site: C1 gallons Comments: A/OT vyrL LA � F'Aqa b0/ o do 57 EEHDInspect,, ,, ,( Reviewed ( Date: Entered Dale: C, V3' By Initial: vv� 1 7.1� By Initial: ` a "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