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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: J c 'laic s Page f of i Facility Address: City: Inspecti Date: �Z3�� % FA #: Z PR #: / Pmnrnmi 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) ElContainers (2821) *of Containers: �TA#: _�� 3'7g� 1 Total Capacity: _ gallons Product Type: 12^ , IL (per tank or cumulative for containers by product type) Install Date: P Tank (2820) ❑ Containers (2821) #of Containers: TA#: Z9 51$ Z ?!T 2Product Total Capacity: �p�j gallons Type: �S (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: 8�7 L Tank (2820) El Containers (2821) 3Product Total Capacity: rM gallons Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Izd'Containers (2821) #of Containers: y TA#: 196j- ?7' I 4 �� Product Type: /�, S^T/ O/�l./ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (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: gallons Total Capacity for Site: (�gallons Comments: 6-2 A G,l- S 5x 7771W-1 li EHD Inspector: Reviewed By Initial: Date: 1 �.ay� Entered Date: By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or movie of petroleum! **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08