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%fte 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 JAI 7—z 0 .L Page of Facility Address: City: Inspection Date: oXe-?-- FA #: PR#: Program Efemen : -3 Z, 1 D5 28 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. IP/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: 3 Eo gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (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 Capacity: gallons Product Type: (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: 3 D gallons Total Capacity for Site: -O gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: VA LA-to-0') 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 09112/08