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a� 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: " 3' 3 Page � of �— r i.— Facility A Idress: City: Inspection Dat 2i -Z-2t7 FA #: PFt 9. Program Element: 3 3 9-5301yo r�-� 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. TA#19!! Tank (2820) ❑ Containers (2821) #of Containers: :51 1 1 // Product Type: �i�lf Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: ❑ Tank (2820) LJ'Containers (2821) 2 Product Type: Total Capacity: /'/0 gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) lld Containers (2821) #of Containers: TA#: 3 Product Type: ��-O%�� Total Capacity: _gallons (per tank or cumulative f r containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative forlfcotiTainers 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: gallons gallons Total Capacity for Site: ZL22 Comments: EHD Inspector: Reviewed Date: By Initial: Entered Date: By Initial:�2 ,��(� `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. FA EHD 28-01 AST SURVEY FORM 09/12/08