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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: 1 1 X'15F'5 n / Page 2— of L Facility Address: city: so I Z/ �. O/t0�� Inspectio Dat . 6 FA #: � PR #:0 � � �. Progr� Edlemen�: 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#: �25f F I? 1 / Total Capacity: gallons Product Type: —�- (per tank or cumulative for containers by product type) i Install Date: ❑ Tank (2820) al6ontainers (2821) #of Containers: TA#: 2 Total Capacity: � 110—gallons Product Type: Z;, --f2 -d e� D I /� (per tank or cumulative for containers by product type) Install Date: L'Tank (2820) ❑ Containers (2821) #of Containers: TA#: d51 R3 S 3 Total Capacity: -> gallons Product Type: ��o (per tank or cumulative for containers by product type) Install Date: VTank(2820) ❑ Containers _(2821) #of Containers: TA#: 5 Lg a 4 3 Total Capacity: S � � Ci gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: e25 -12s=-3 5Product Total Capacity: - r) gallons Type: ��/iS.�T� cl (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: �� gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed By Initial: Date: Entered Date: By Initial: LO �b DGY `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 09/19/08