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SAN aJOAQUIN 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: �-.L o Page -�— of Facility Address:y: 14 Inspect' n Dat FA #: PR M Program Elerx)ent: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#:��02 1 Product Type: Total Capacity: �� gallons (per tank or cumulative for c ntainers by product type) Install Date: L'�3' Tank (2820) El Containers (2821) #of Containers: TA#_�� q3a� 2�, Product Type: Total Capacity: , '� gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 6-I q 3 3 3 Product Type:.e Total Capacity: t^ gallons (per tank or cumulative for containers by product type) Install Date: Ef Tank (2820) ❑ Containers (2821) #of Containers: TA#- ��1 0( 3� 4 �' Product Type: Total Capacity: � � gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) © Containers (2821) #of Containers: Y TA#: 410T., q1_3021:tT 5 / Product Type: O Total Capacity: / gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ( gallons Total Capacity for Site: ,rte C gallons Comments: C. J l 71, EHD Inspector: C ' Reviewed ( Date: By Initial: 1 r^ Q �� " d'�� 1 Entered ] Date: By Initial: <;-' r ` Q/ /, �' L *Abovegrounestorage 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