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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN-i 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 O ' �;�1A,'� W1?Ak Page I of Facility Address: rr � Inspection Date: � City: I I �'t t �Q,SZ`it I�O�� FA#: PR#: Program Element: 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. f Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 city: gallons Product Type:Total Ca a (per tank or cumulative for containers by product type) Install Date: I� Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2Product Type: ✓ Total Capacity: �0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ 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: I L_ 5U gallons Total Capacity for Site: l'1 S(j gallons Comments: If EHD Inspector: n Reviewed Date: Entered Date: By Initial: By InitiaC `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