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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: r l,- I)q k 1 Page / of Facility Address: City: Inspection o � LC& FA#: PR M Program Element: 3 0 1 Z R Z 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. n ank (2820) ❑ Containers (2821) #of Containers: TA#: a 5 / '7 1 Product Type: �r Total Capacity: -7o�� gallons 2 (per tank or cumulative for containers by product type) Install Date: VTank (2820) ❑ Containers (2821) #of Containers: TA#: 05-/-79 2 AJ Product Type: Total Capacity: / l� �� gallons �---= (per tank or cumulative for containers by product type) Install Date: C1,1ank (2820) ElContainers (2821) #of Containers: TA#: 3 Product Type: Total Capacity:/n 1,��/� gallons (per tank or cumulative for containers by product type) Install Date: F ,iK (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: t gallons Comments: EHD Inspector: Reviewed Date: Entered Date: CBy Initial: �,�Q•(1 By Initial: f i v ' *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