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C 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 PROG)Ft4M SURVEY FORM Facility Name: 1/V /NT��(� _7E Page of Facility Address:_ Ci S --7-11 C -)L 0 rV' Inspection ate: � FA #: PR M Program E e 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) 11Containers (2821) #of Containers: TA#: D5J 73D 1 Total Capacity: Z7gallons Product Type: UZ (per tank e o con ai tacit t pe) Install Date: Tank (2820) C/ Containers (2821) #of Containers: f TA#: OV�I 73I 2 r Product Type: Tota _ a Ions - g er tank or cumulative for containers by product ty Install Date: ❑ Tank Vcontainers #of Containers: �_ TA#: �' $-3a (2820) (2821) 3 -Product Type: V �7;T�tJ �J 4 o/ Total Capacity: ZZJ gallons ��— (per nk or cumulative for roduct type) Install Date: Tank (2820) ❑Containers (2821) #of Containers: TA#: 4;j<;733 4 Total Capacity: l D'�% gallons Product Type: ►' /� (per tankor cumulative for contamers b odact type) �� Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: _ g 5 Total Capacity: 2ryf gallons Product Type://,,/ 0 (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 gallons Total Capacity for Site: 31LO gallons Comments: EHD Inspector: C Reviewed1,�, Date: By Initial: Entered By Initial: Date: lJ`�' *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of pe roleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08