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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* Page of f/ 1jliG0 fAR S Facility AddesyInspection Date: 17q3 11A-1V (Lru a FA#: PR#: Program Element: 6o d 2930 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers". Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) ERContainers (2821) #of Containers: TA#: 1 Product Type: JyA Total Capacity: J / C3 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: D,s j Ss�f 2 Total Capacity: 60no gallons Product Type: Y (per tank or cumulative for containers by product type) Install Date: It Tank (2820) ❑ Containers (2821) #of Containers: TA#: 42,h 3 Total Capacity: 3Pj gallons Product Type: (per tank or cumulative for containers by product type) Install Date: C]ffank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: 0-70 gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: oZ .,nk (2820) El containers (2821) 5sProduct Type: . �n X� Total Capacity: r _ gallons (per tank or cumulative for containers by product type) Install Date: di P Total Capacity this Page: o gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: V 10•tg� I __'j 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