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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: /' ' Irl -y'f✓o�r ////✓/% Pagel of Facility Address, City: Inspectio 2 r) 3 fir- t jar' FA#: PR M Program'Element: / '7/ 3 2 - I 6bCf � 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) ❑ Containers (2821) #of Containers: 7 TA#: 1 ' r— r-() Product Type: Total Capacity: .lo� .i gallons (per tank or cumulative for containers by product type) Install Date: E�KTank (2820) ❑ Containers (2821) #of Containers: TA#: L$' 2 f-- Product Type: /_T" `j Total Capacity: ��.� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity: �G L gallons ❑ Tank (2820) EI/Containers (2821) #of Containers: / TA#: 3 i Product Type: ZyA T/e r (per tank or cumulative for containers by product type) Install Date: /Tank (2820) ❑ Containers (2821) #of Containers: TA#: �h 5? Product Type: Sl-- l''"e'- 4 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: EHD Inspector: h > Reviewed Date: Entered Date: By Initial: 4"W. 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