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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: c.c) C E-A r M S Page - of Facility Address: Al' /D vnV C A W City: a Inspection D e: � FA #: PR M Program Element: 0 -2-g30 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: TA#: i9,5'/ �p�Z 1 Total Capacity: gallons Product Type: m (per tank or cumulative for contbi ers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 66-12 D.22� 2 Total Capacity: gallons by Product Type: (per tank or cumulative for containers product type) Install Date: LTJ Tank (2820) 1:1 Containers (2821) #of Containers: TA#: N 3 Total Capacity: 06 gallons Product Type: (per tank or cumulative for contafners by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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:/ 5— CIO gallons Total Capacity for Site: gallons Comments: 7-T C R 0 C- X 0/`" EHD Inspector: �r Reviewed Date: By Initial: C Entered Date: By Initial: �_ "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of pbtroleumr "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08