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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM yi eni Page of Facility Address:t --� �� t r `J City: 11 U'C. L Ins erti n Da e: (L, FA # PR #: C) %� l / 7 ProgFa Element: 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. 'D- Tank (2820) ❑ Containers (2821) #of Containers: TA#: ^� 1 Total Capacity: I �' � gallons Product Type: �� Ale) YP ��-' (per tank or cumulative for containers by product type) Install Date: Q"Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2, Total Capacity: (� � " , gallons Product Type: t BSO' (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#:�� 3� Total Capacity: (% gallons Product Type: (per tank or cumulative for containers by product type) Install Date: .�]- Tank (2820) EJContainers (2821) #of Containers: TA#: �qLS�A� D -� 4 Total Capacity: gallons Product Type:_tiV i t✓ c)1 (per tank or cumulative for containers y product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: P Y� � � V gallons Product Type: '� �� ib�iW1�(,,, / 0 , (per tank or cumulative for containers by product type) Install Date: f _1 ' A v'y11 �.6-o Total Capacity this Page: Z� gallons I Total Capacity for Site: � � C) gallons Comments: EHD Inspector: *Ah .. A .--- Reviewed Date: By Initial: q -11 -to TEyntered Date: itial: /) Avvvcvui U awidyC tdnK means a tanK that nas 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