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SoSAN 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: �jj ' y hr C/ Page of Facility Address: City: Inspect' n D e: FA #:PR '719 M Progra Elemenji 1 Z Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks` and containers`*. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 696:12!Z -"V 1 Total Capacity: / 04"gallons Product Type: D. (t 4AU (per tank or cumulative for containers by product type) Install Date: GP Tank (2820) El Containers (2821) #of Containers: TA#: / �c% b ,�- 2Product Total Capacity: / 00-e ' gallons Type: _ A,5 (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: 0 Ogallons Product Type: o _ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: 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: �.� gallons Total Capacity for Site: / �� gallons Comments: EHD Inspector: Reviewed By Initial: , Date: � � 14j Entered By Initial: Date: `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