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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: Ilk IN T Page —4—of f Facility Address: City: Inspection D te: 2-95 �ossa�� !� -I', FA#: PR M Program Elem t: 5 Tank/Container Information Complete for all sites with cumulative aboveground storagef petroleum 21,320 gallons in tanks*and can rs". Complete one box for each tank or each umulative container rodu tainers:Tank (2820) Containers (2 TA#: uctTy1 pen / Total Capacity: 7 lgallo s (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Conta ers: TA#: 0,- 2 Total Capacity: Jy gallo � (per tank or cumulative for containers by product type) nstall Date: Tank (2820) L1 Containers (2821) #of Containers: TA#: 6 — `l . t 3 Total Capacity: l d 0 (L gallons Product Type: ��{ () (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (pertank or cumulative for containers byproducttype) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (pertank orcumulativefor containers by producttype) Install Date: Total Capacity this Page: / ' 0 ' gallons Total Capacity for Site: b gallons Comments: EHD Inspector: Reviewed � � �p Date: Entered Date: By Initial: 1Jv1V ( T By Initial: 1 a *Aboveground storag&bnk 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