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t 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:� D � b age of Facility Address: City: Inspecti n Dat j: FA #: 6 S�s PR #: a Program Element: .2-;330 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. ank (2820) ElContainers (2821) #of Containers: TAS#: 1 Total Capacity: % (ja l% gallons Product Type: /'�,l.P� (per tank or cumulative for containers by product type) Install Date: U--- (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: � gallons Product Type: /�S' 2 (per tank or cumulative for containers by product type) Install Date: #of Containers: �_ TA#: % 3D g ❑ Tank (2820) aContainers (2821) 0ac;__ 3 Total Capacity: 5a)gallons Product Typed (per tank or cumulative for containers by product type) Install Date: VTank(2820) ❑ Containers (2821) #of Containers: : 42�Z /'Fc- lP? 4 —' Product Type: Total Capacity: Sy gallons (per tank or cumulative for containers by product type) Install Date: IV4 G -o ED ank (2820) ❑ Containers (2821) #of Containers: TA#: ©V�� 93 1 o 5 Product Type: Total Capacity: /' Pa U gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 3 (, gallons Total Capacity for Site: gallons Comments: EHD Inspector: J Reviewed Date: By Initial: VIA q-' rj_pO� Entered Date: By Initial: -- *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