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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95262-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY. FORM Facility Name: C Page —/---.of Facility Address: f City: Inspection ate: r - o tz.1150 FA#: PR/�?zg Progr�lTq� nt: Tank/Container Information Complete fo 11 sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers". Complete one box for eacI4 tank or each cumulative container Rroduct type. VTank (2820) ElContainers (2821) #af Containers: ,TA#: 1 Total Capacity: --- (� gallon Product Type: g - (per tank or cumulative for c ntainers by product type) Install Date: ank (2820) 11Containers (2821) #of Containers: .1 2 Total Capacity: gallons Product Type: (per tank or cumulative for&hhlatners 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: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Tatal Capacity for Site: ✓ gallons Comments: 1 `�-- EHD Inspector: Reviewed Date: Entered Date: By initial: Wtjlfi.at.091By Initial: X//.,- *Aboveground storage tan 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