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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: C / + � I"A/7M Y Page of Facility Address: City: Inspee on Mt +5 - ItiA MrrLM 13 r FA#: PR#: Prog am Ele e OP122a62n 19 Tank/Container information I 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!Xpe. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: 51-fo gallons Product Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: -W Tank (2820) ❑ Containers (2821) 2Product Type: Total Capacity: --op gallons --'�' (per tank or cumulative for containers by product type) Install Date: M/Tank (2820) ❑ Containers (2821) #of Containers: -h TA#: 3 Product Type: t17' J' Total Capacity: 2-0d gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TA#: 4 Product Type: r Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: 4 ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: galions Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: e2rgallons Total Capacity for Site: Cj gallons Comments: t EHD Inspector: Reviewed Date: Entered Date: By Initial: �.�(,l' By Initial: 5 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!12108