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SAN JOAQUIN COUNTY s 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: r^� Page / of Facility Address: - City: 3 S c 1J , Aq Vi5 /�11 Inspection 1 �/ - FA #: i Z PR M I O6 ( & Program Element: TanWContainer 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) El Containers (2821) #of Containers: TA#: i9,5 j l 4 1 Product Type: /� Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 6 g I L+ 2Product n Total Capacity: / �� gallons Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: `5 1 �' ► 4b 5, -'rank (2820) El Containers (2821) 3 � Product Type: Total Capacity: �% U 0 gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) C3 Containers (2821) #of Containers: _v TA#: 4 Total Capacity: ),/17 gallons Product Type: Y (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Containers (2821) #of Containers:. TA#: 6,6-1 �I 5 lJ� Total Capacity: J - , gallons Product Type: ,�� r'7 7WZ, OP (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 G gallons Total Capacity for Site: 3) S gallons Comments: EHD Inspector: Reviewed Date: By Initial: lt. gyp• ( Entered Date: By Initial: I/ "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