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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: C O /`UST /� A^I P- 4 Page �_ of Facility Address: Inspects Dat L R iq ;e A"/ / 1U FA A: PR X: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tanks'and containers". Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (2821) #of Containers: _,3 — TAM 1 Total Capacity: �- gallons Product Type: /7(2y ` (per tank or cumulative for containers by product type) Install Date: ank (2820) ElContainers (2821) #of Containers: lfA#: 2 Z C Product Type: Total Capacity: gallons (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: TAM 4 Total Capacity: gallons Product Type: (par 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: gallons Comments: /j c -g 9 zC'9 Sz0�= EHD Inspector: C. Reviewed Date: Entered Date: C� By initial: C6_�_ 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 28-01 AST SURVEY FORM 09/12/08