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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(,l Arn F ok /C>%1Q Page Lof Facility Address: o ;&LIL City: v Inspec •on Dae �y�� FA #: PR M 7 0 5,3o ro Program ent: 8 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. a-fank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: `�� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: M—Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 /Product Total Capacity: O -/ gallons Type: l� (per tank or cumulative for containers by product type) Install Date: 0' -Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 2 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for contain rs by product type) Install Date: ❑ Tank (2820) EAontainers (2821) #of Containers: TA#: d� 5 _' Total Capaci�: �Z8 gallons Product Type: � I1 T D% (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: -Z Zit) gallons Total Capacity for Site: 3 -Z' Z4 gallons Comments: y EHD Inspector:Reviewed A/- By Initial: Date: U IIpi Entered By Initial: Date: ev 129 "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