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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: n - s C H r n/ON0 Page of Facility Address: City: Ins on D FA#: PR#: Program Elennitn •� 09 B5 -2- Tank/Container 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. (Y'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1Product Type: rJ.c� Total Capacity: � S b gallons (pertankor cumulative for containers by product type) Install Date: Cly'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: 5" gallons Product Type: /�/n/y (per tank or cumulative for containers by product type) Install Date: /� / /'//P�/fry ❑ 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: TA#: 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: S D gallons Comments: G N/ C Zv rr 00 EHD Inspector: Reviewed Date: Entered Date: By Initial: VAC6--J- By Initial: a '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 2801 ASTSURVEYFORM 09/12/08