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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 Name: / C L1,55/�� Page of Facility Address: City: Date: Insp71,-k(o r— Gv 12a q FA #:/ PR M a� Program lement: 'Z-7.3 0 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. El i,T^ank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: / jj O gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Ullank ❑ #of Containers: TA#: (2820) Containers 2821 2 Total Capacity: _ gallons Product Type: (per tank or cumulative for containers 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 Product Type: Total Capacity: gallons (per tank or cumulative for containers 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: "Z O C20 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed By Initial: Date:Entered 1!i-��(j 0� y dl: Date: 1q "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 AST SURVEY FORM 09/12/08