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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: /� �� r f �S Page of Facility Address: //- _ Z City: 6-ry Inspection ata: Il � FA #: 6 PR M Progra a ent: 7r IT D� 17) 5-00 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. U Tank (2820) EI Containers (2821) #of Containers: TA#: 05I q D L_ 3 1 Total Papacity: t9 -,0_e'7 gallons Product Type: ir�l9 f (per tank or cumulative for containers by product type) Install Date: t ank (2820) ElContainers (2821) #of Containers: TA#: ,r 27 Total Capacity: S gallons Product Type: 0•{.�� G (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820)Containers (2821) #of Containers: A#: 3 Total Capacity: /3-G gallons Product Type: -7 1-9 (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Contain rs: #: (�,�/ q'910i 2 4 g Total Capacity: � � gallons Product Type. (per tank or cumulative for containers by product type) Install Date: El Tank(2820) 21 Containers (2821) #of Container : TA#: B 5 Total Capacity: acit Jgallons :' Product Type: J (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: S7gallons Total Capacity for Site: 2 sr gallons Comments: EHD Inspector: C Reviewed Date: By Initial: g .l1 Entered Date: 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