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' SAN JOAQUIN COUNTY 40 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: Page of Facility Address: p L fA G9 ity�� rK r Insp) Dp�� FA#: [/ PR#: /`r Program Element: 3tO-7a 3 � 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. 13 Tank (2820) ElContainers (2821) #of Containers: TA#: 0/ 1 Product Type: �7 6 1�� Total Capacity: L / � gallons (per tank or cumulative for containers byproduct type) Install Date: Tank (2820) [I Containers (2821) #of Containers: TA#: d5 l / 2 g Product Type: Y 17 n4�� G D i Total Capacity: �. gallons (per tank or cumulative for containers by product type) Install Date: M�Tank (2820) El Containers (2821) #of Containers: TA#: 3Product Type: 1'1:4S Total Capacity: �-�� gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: 4 Total Capacity: 7 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: �n I �/'�➢1�'p /V El Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 r Product Type: Total Capacity: � n+J gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this PagS019/J gallons Total Capacity for Site: -Z_p--r,® gallons Comments: yob Zai /- � I'/ /©/3-A EHD Inspector: Reviewed Date: �,q Entered Date: C U j By Initial: 19-fj- L l By Initial: 1 917 "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