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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: / , rof ,v Pae Facility Address: City: Inspection D te: z'0-)Se1r7 11"Zk FA#: PR#: c Program Elam 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) n Containers (2821) #of Containers: TA#: 1 � 5-�, Product Type: Total Capacity: �gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: d 2 Total Capacity: -3 5y gallons Product Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: 66-11-7 1 `7 Tank (2820) ❑ Containers (2821) ^✓�� 3 Total Capacity: 1 p p (?gallons Product Type: / J (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: TAM 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: / V o gallons Total Capacity for Site: / 700. gallons Comments: EHD Inspector: Reviewed � � �p Date: Entered Date: �1 By Initial: Vv`j -(�-O'� ey Initial: 1 �1 *Aboveground storagdlank 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