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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: JS 6d /� Page -2—of Facility Address: city: Inspe ion D te:.4"p) n FA#: PR IF: Pro ram Eleme t: 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: � 1Product Type: Total Capacity: j � gallons ---� (per tank or cumulative for containers by product type) Install Date: tr/Tank (2820) ❑ Containers (2821) #of Containers: TA#: -4"5-1 Lo 2 Total Capacity: r f) gallons Product Type: (per tank or cumulative for containers b (p y product type) Install Date: x f-- Ej� Tank (2820) ❑ Containers (2821) #of Containers: TA#: P51 3 Product Type: Total Capacity: ,5,�� gallons (per tank or cumulative for containers by product type) Install Date: /e ni Zt/R ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (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: r, gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: it 'u 0 *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