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1 r 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: /^�'/�/'� �2 A�4!✓r�� !� �'��v �i2' Page of .Y_. Facility Address: C.ty: Inspection Date: 0 fi-7 s- / 'r,(--k-- Z 4-1��,/ �' ) FA#: r PR#: Prog�am Element 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. f #of Containers: TA#: /95/y/9 WT ©` Tank (2820) El Containers (2821) 1 Total Capacity: -",2 Pd gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TA#: 2U Product Type:Total Capacity: /�� gallons yp f2-c��u (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total y: gallons Capacity: Product Type: p (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total y: gallons Capacity: Product Type: p (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: e p gallons Total Capacity for Site: gallons Comments: EHD Inspector: �� Reviewed Date: Entered Date: (� c� By Initial: 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