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00 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: � Page —./— of Facility Address: 9 C X TO City: Inspection Date - nl2Z2-7o? FA #: `7 3 S PR PR #: -3 o a- Prog a Element: -z 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) ElContainers (2821) #of Containers: TA#: ' 1 Total Capacit O Jgallons Product Type: (per tank or cumula : for containers byproduct type) Install Date: C4ank (2820) ❑ Containers (2821) #of Containers: TA#: n 2 Total Capacity: l b O 0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 1575 gC¢(v 3 Total Capacity: �' gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank [�ntainers #of Containers: TA#: SI �a Cv (2820) (2821) 4Product Type: Total Capacity: _ S,5gallons (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: 5 gallons Total Capacity for Site: /) �� gallons 7 Comments: EHD Inspector:Reviewed ✓ Date: By Initial: V �. b @� Entered Date: By Initial: B *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petr-oleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08