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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: Cy%,' P0i9�f' �' t � Page of a— - Facility Address: ') (�,C City: (� / o �v ��!��/� Z V % SIV e `��_ Inspection D te: O� �� l FA M PR M Pro& am E ment: 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) ❑ Containers (2821) #of Containers: TA#: 1 , Product Type: --7'))�1 k . Total Capacity: � L � C/ gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Containers (2821) #of Containers: TA#: 2 - Product Type: Total Capacity: � -D :� � gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: C. (? '�� r✓/ gallons (per tank or cumulative for cont ners by product type) Install Date: ❑ Tank (2820) XContainers (2821) #of Containers: TA#: 4 .� : Product Type: , ( �' Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Xcontainers (2821) #of Containers: t-12— TA#: 5 Product Type: f�, i�01-0=' (-7//Total Capacity: ��, ��' gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: �� 2�1�) gallons Total Capacity for Site: /=� gallons Comments: 2 L 'C- J 2 EHD Insp ctor: Reviewed Date: Entered Date: �{ By Initial: By Initial: *Above -rou d'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