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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: I Y �. L t'1 Page of b [ A L Facility Address: City-: Inspectio Dat t_ FA#: PR#: Progra EI menta 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. Ll� Tank (2820) ❑ Containers (2821) #of Containers: TA#: Q� ( RAI 107 1 Product Type: CA Total Capacity: 61049 gallons Z61049 S 0 (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: d 5 $ g 2 J Product Type: Total Capacity: 1�t ! gallons (per tank or cumulative for containers by product type) Install Date: 2'/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 �--] Product Type: Total Capacity: / �� gallons (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: j �� gallons Total Capacity for Site: '—'5—C)` gallons Comments: EHD Inspector: �� Reviewed Date: Entered Date: i� By Initial: Ct.� By Initial: �v *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