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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: „L Sn L /%N% '/IS.ES Page of Facility Address: City: S 9 7/ Ins ec�tion IZ FA #: /70 PR #: Program Element: L 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: i TA#- B 1Product Total Capacity: Z o o � gallons Type: (per tank or cumulative for containers by product type) Install Date: I//Tank (2820) ❑ Containers (2821) #of Containers: TA#: D 2 Total Capacity: �n gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Er"Tank (2820) ❑ Containers (2821) #of Containers: TA#: Di—y D 14 3 - �Product Type: Total Capacity: S -P gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) E Containers (2821) #of Containers: �_ TA#: B (�S D 4 Product Type: /'�'/% 7—d — 1) Total Capacity: J� gallons (per tank or cumulative for containers by product type) Install Date: 13"Tank (2820) ❑ Containers (2821) #of Containers: TA#: g"D 5 Product Type: Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 3 gallons Total Capacity for Site: 3 (?� gallons Comments: EHD Inspector: Reviewed Date: By Initial: y.'�. C� Entered Date: By Initial: 7;/,(? *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