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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• .� _ Y T Page / of Facility Address: city. Inspecti D t YP 7 FA#: PR#: Program'67, 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) El Containers (2821) #of Containers: TA#: X9,45-1 8`f 7 0 1 Product Type: Total Capacity: _l--a z) gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: !��) $`-�-`7 2 Product Type: J Total Capacity: %0 U� gallons (per tank or cumulative for containers by product type) Install Date: L?'Tank (2820) ❑ Containers (2821) *of Containers: TA#: L95 3 Product Type: Total Capacity: ,�v� gallons (per tank or cumulative for containers by product type) Install Date: L�f ank (2820) ❑ Containers (2821) #of Containers: TA#: 4 C� Product Type: e'�' (� / 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: 2 (��► gallons Total Capacity for Site: gallons Comments: EHD Inspector: z - Reviewed Date: Entered Date: By Initial: Vj� -),'LO 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