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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: r� C u M / /4 /V C� I Page __L__ of FacilityAddress: D- �rJ City: Inspect! Date: I 1� FA #: I IPR fr7Zgq M e'5-c-�OQ 73 Program Element: 2,g 30 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. ,__ 2 -Tank (2820) ❑ Containers (2821) #of Containers: TA#: S 1 S Product Type: Total Capacity: L/ �� gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: 12 I g ��o lei' Tank (2820) ❑Containers (2821) 2 Total Capacity: 50:6 — gallons Product Type: 1'�A (per tank or cumulative fog containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: (�,h / $'[oq % 3 > Product Type: Total Capacity: (�v gallons , (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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 Total Capacity for Site: ®� gallons Comments: EHD Inspector:/1 Y (j Reviewed By Initial: Date: kA'1-�.0� Entered DaLo-� By Initial: t *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