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40 SAN JOAQUIN COUNTY 40 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 �;� � Page 2 of Facility Address:// City' ( G/ ^ L �rl�U Inspection gate: '7 FA #: D / C) 4 PR #: 1 Program Element: 25 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. 1 ❑ Tank (2820) Acontainers (2821) #of Containers: , + 1 TA#: P�/�'S%,� aA�-� Product Type: �'�t'�/I �'' U Tota apacity: gallons fnw per tank or cumulative for containers by product type) Install Date: (t1 bio oifh l' ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: I �%CT gallons Comments: EHD Inspector: 1 J Reviewed Date: By Initial: Entered Date IO By Initial: n r,uovegrouna storage xanK 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 09112108 AST SURVEY FORM