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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: CPage —L— of Facility Address: S. City: Inspec Ion Date: 2d9l Z$ D FA#: PR#: Pro m le nt: d d6a4 2 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks'and containers". Com le one box for each tank or each cumulative container product type. ❑ Tank (2820) Illontainers (2821) #of Containers: „L_ TA#: 1 �� Total Capacity: SS gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: 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: (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: gallons Total Capacity for Site: 5 gallons Comments: azo A 71d EHD Inspector Reviewed Date: Entered Date: ll�By Initial: r�.,�j U9 By Initial: z 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. ho f "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08