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r , 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: ff �/X'V _ , ]�1�^ i j. Page of Facility Address:. Cit / i� Inspection ate: #' PR M 10, Prograni Element o� -12- �3 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. 9-Tank(2820) ❑ Containers (2821) #of Containers: TA#:i T� q 1 r` Total Capacity: J gallons Product Type:/;' r% (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) P Containers (2821) #of Containers: �_ TA#: (p 2Product Total Capacity: gallons Type: _ JL�S (per tank or cumulative for containers by product type)A% Install Date: / le A/° lvA �D 2 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: 3 0, 90 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑Containers (2821) #of Containers: TA#: f g lea 4 Total Capacity: it L� 6 gallons Product Type: %7,�:��a�-�/ (per tank or cumulative for cont finers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: /,0 gallons Product Type: C'5� G (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ` j 0 gallons Total Capacity for Site: % 000 gallons Comments: - 11/ EHD Inspector: " ✓ Reviewed Date: By Initial:kJ4,11. r7� Entered Date: By Initial: tt b *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