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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: D 11a 41 r. L q Page of Facility Address: City: Inspection Date: Dcom TOGIC. - 3'09 FA#: PR#: Progralln Element: 65 Z' O 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. EY/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: .300 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: CH'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: 3 n O 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: TA#: 4 Product Type: Total Capacity: 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: gallons Total Capacity for Site: d gallons Comments: [E�Ho�Inctor ./� Reviewed Date: d Entered Date: SCJ By Initial: � t{-b•b ` 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