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l.r SAN JOAQUIN COUNTY -qwle 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: 5 Page L Of SCl6 R Facility Address: o City: Inspection ate: 2 C- % c C /O FA#: PR M Prograrii Ele ent: ? obi aoq a i:7 T'" 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. t ank (2820) V Containers (2821) #of Containers: T4A-�#::J 1 Product Type: (:A F d Total Capacity: ]� � gallons (per tank or cumulative for coonnta�ers by protluct type) Install Date: Z Tank (2820) ['Containers (2821) #of Containers: TA#: 2 Total Capacity: 10 "V gallons Product Type: S a l (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers:Total Capacity: 7 D v TA#-. 3 � , dl gallons Product Type: �� (per tank or cumulative for containers by product type) Install Date: El Tank (2820) a ontainers (2821) #of Containers: TA#: S 4 Product Type: 41ti Total Capacity: 1 / 0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: D gallons Total Capacity for Site: gallons Comments: . a W gf us Ci Nd EHD Inspector: ReviewedC ' - _1 Date: Entered Date:- By Initial: VA (X)30- By Initial: / `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