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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: 1�Al%, fvC/' Page of Facility Address: City: 6 c� tt �' 7-6 rl AL Inspecti n Dat r �= FA #: PR #: s, C Program Element: 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. 0 Tank (2820) ❑ Containers (2821) #of Containers: rTA#: A6 1 SIP 7 D 1, Total Capacity: / 0 � ©� allons Product Type: /'�.! �_D x (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 / Total Capacity: %,�.� - � � gallons Product Type: (per tank or cumulative for containers by product type) Install Date: i C�Tank (2820) El Containers (2821) #of Containers: TA#: (g/� % a 3 Total Capacity: loo?) gallons Product Type: U�� J. (per tank or cumulative for containers by product type) ❑ Tank (2820) f,nnfniners (2821) Install Date: #of Containers: TA#: c 4 Total Capacity: gallons Product T�- (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: - ' gallons L, U Total Capacity for Site:gallons Comments: EHD Inspector. / "' Reviewed Date: } By Initial: vtj '�. b-0 Entered DateWw By Initial: D *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