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SAN JOAQUIN COUNTY j y 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: C L c L /i -T-1 m r Fpgmr Page of Facility Address: City: InspecoryDDaat'e r� FA #: PR M D5 <3 Program Ele"7 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#: 1Product Type: Total Capacity: � � �j gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA_ #:: 5 On to 2 Product Type: Total Capacity: gallons (per tank or cumulative for con ain rs by product type) Install Date: C�/Tank(2820) ❑ Containers (2821) #of Containers: #: /q e o � & U o 3 /l -TA_ Total Capacity: y gallons Product Type: (,�� (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: —1 g �� CYTank El Containers (2820) (2821) 4 Product Type:p Total Capacity: gallons t� (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: b6- 1 S (QOg2 5 0 0 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z3 S -C) gallons Total Capacity for Site: 3 gallons Comments: FE�D Inspector: \ TRevievved Date: y Initial:b,g�I Entered Date By Initial: "Aboveground age tank means a tank that has the capacity to store 55 gallons or more of petrole m. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08