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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 Na . Df L me�/ D p Facility Address• qcontainers". of /to Cl��/fJ- pFA#: P #: nt:o�a4��s oTank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 11,320 gallons in tainers".Com lete one box for each tank or each cumulative container roduct t MI/Tank (2820) ❑ Containers (2821) #of Containers: TAS#:: 12IS-lR 1 -7 ,9, 1d Product Type: �7- S d Total Capacity: /b 0 gallons (per tank or cumulative for containers by product type) /Tank (2820) ' Install Date: Q Tank (2820) ❑ Containers (2821) #of Containers: TAM /9 18 173 2 � Total Capacity: gallons Product Type: (per tank or cumulative for cont mars by product type) Install Date: ❑ Tank (2820) ontainers (2821) #of Container : TAM R 17� 3 Product Type: Total Capacity: 'L" gallons (per tank or cumulative for containers by product type) 9--Containers � Install Date: El Tank (2820) L�3 Containers (2821) #of Containers: TA#: LE 4 Total Capacity: 'L gallons Product Type: �/� Q� (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ontainers (2821) #of Containers: �_ TA#: P, 5 Total Capacity: -Z-4- gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacitythis age: 0 gallons Total Capacity for Site: gallons Comments: o r ✓711a EHD Inspector: Reviewed Date: Entered Date: By Initial: -�.(� By Initial: D *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 09/12/08 AST SURVEY FORM