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SAN JOAQUIN COUNTY 09 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: �, Page of Facility Address AlP "S City: Lo 0 Inspecti 7e: %s' r i FA #: 9 PR #: � 1 Program EI m t: a 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. 0 `Tank (2820) ❑ Containers (2821) #of Containers: TA#: 19 ',h �2 1 Total Capacity: d O ® gallons Product Type: �2z�&) (per tank or cumulative for containers by product type) Install Date: �/ / Tank (2820) ❑ Containers (2821) #of Containers: T�AQ#: eh j�%�/o,� 2�� Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: � Tank (2820) ❑ Containers (2821) #of Containers: TA#: /)h L��P -5 3Product Total Capacity: ,�0� gallons Type: (per tank or cumulative for containers 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: C'4-2 gallons Total Capacity for Site: 3 V --o gallons Comments: EHD Inspector: Reviewed Date:Entered By Initial: 1v, By Initial: Date: 'J? l ( "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