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SAN JOAQUIN COUNTY .1 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 Name6 / 7- T O h D C H L71 P-DS Page of Facility Address: City: Inspection Date 3 FA#: 172, �� D PR k: — _ Pro m Elgm_ent: Tank/Container Information S 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. rank (2820) ❑ Containers (2821) #of Containers: ;TA#: 1 Total Capacity: p Product Type: a�� �gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 57vProduct Type: ✓Y! .S g / Total Capacity: 3 � 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 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: a gallons Total Capacity for Site: O5-0 gallons Comments: EHO Inspector: Reviewed Date: Entered Date: Kr By Initial: k1At�, 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 2801 AST SURVEY FORM 09/12/08