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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: DA R Page of Facility Address: City: Inspection D p S/�/ �•l FA #: PR M Progra it1_ezme_nt: 3 a a ✓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. Tank (2820) ❑ Containers (2821) #of Containers: . TA#: ? D 1 Product Type: 0404et Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: O L'5-( 2' 3 ? I 2 Product Type: l p S 2/ Total Capacity: % gallons (per tank or cumulative for containers by product type) Install Date: IV�Tank (2820) ElContainers (2821) #of Containers: TA# 3 Total Capacity: OcV a gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) n-6ontainers (2821) #of Containers: TA#: ? 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) 11Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: / S gallons Total Capacity for Site: / gallons Comments: EHD Inspector: Z Reviewed Date: By Initial: VIA 0"'t Entered Date: By Initial: *Abovegrounc7storage 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