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ft 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: f ,•: /� (e = L CE i8- � � A � ltil S �( Page of Facility Address: City: Insnn O G /�� FA #: 3 Z� PR #: Program Element; -�ddTf7�c�/QQ p Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks` and containers**. Complete one box for each tank or each cumulative container product type. ' D Tank (2820) ❑ Containers (2821) #of Containers: TA#: .9,o�_ 1 Total Capacity: 2 C9��I gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ID/Tank(2820) ❑ Containers (2821) #of Containers: ITA#: 5L6 -Z ! (3 2 Total Capacity: �� gallons Product Type: �✓LP (per tank or cumulative for containers by product type) Install Date: 11Containers #of Containers: TA#:12 =Iez I a/Tank (2820) (2821) 3 —" Total Capacity: J gallons Product Type. - (per tank or cumulative for containers by product type) Install Date: Lit" Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4Product Total Capacity: �� gallons Type: 0 (per tank or cumulative for containers by product type) Install Date: t. Tank (2820) ❑ Containers (2821) #of Containers: TA#: a,, 5 -j q' 3r7 5 Total Capacity: U� gallons Product Type:i S % (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: -3750 gallons Total Capacity for Site: L/ gallons Comments: 6� L L6 v 3`' 26 % EHD Inspector: / Reviewed Date: By Initial: Entered Date: By Initial: l �. t, 1 t le "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