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SAN .IOAQUIN 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: o 0r- i Fr CAS Page of y Facility Address: City: C� V c)N N17 r(, S T p kfn c-� Inspection Date, � � 4 FA #: i0339 PR M a l,6 -0z) — Program Element: -"' �30 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. �nk (2820) ElContainers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: _gallons (per tank or cumulative for containers by product type) Install Date: 0,-ra'n k (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: � a b d gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: TA#: 4,rL 3Product Total Capacity: / � gallons Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) LTGontainers (2821) #of Containers: TA#: 4Product Total Capacity: ,s,J gallons Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) CEJ -Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: 4 0 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: � rL- EHD Inspector: Reviewed Date: By Initial: 1 R� 1 ��,.ii� Entered Date: By Initial: *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. -AHD 28-01 AST SURVEY FORM 09/12/08