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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN0 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 Na C'T L (� Page of Facility Address: �+ j Inspection Date: PR M Program Element: z�31 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) ❑ Containers (2821) #of Containers: TA#: 1 e: Total Capacity: /000 Product Type:Yp !'ax cQi es.. / (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: lr)6-)Q$4D 2Product Type: e P Total Capacity: 000 gallons reSPi/ (per tank or cumulative for wntainers by product type) Install Date: 'k-Tank (2820) ❑ Containers (2821) #of Containers: TA#: )_q 84/-/ 3 Total Capacity: 2>p0 gallons Product Type: ntainers by pro (per tank or cumulative for wduct type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: _� TA#: L��a 4 Total Capacity: / (�S gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: Product Type: p Y� _ gallons (pertank or cumulative for containers byproducttype) Install Date: Total Capacity this Page 5 gallons Total Capacity for Site: gallons Comments: EHD Ins or: Reviewed Date: Entered Date: By Initial: V,dJ �'•Lb•(D By Initial: Itooveground storage tank m;a:ns: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 09/12/08 AST SURVEY FORM