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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: 'Hom,q ka� Page - of so-ly NC l , Facility Address: k�To Cit : Inspec 'on D e: ' D e ��P� FA #: PR #: `g� ren 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) E-1 Containers (2821) #of Containers: 1 Capacity: / 0 0 0 gallons Product Type:Total STA#:moi (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: -7 D 2Total Capacity: gallons % Product Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: El Tank(2820) Containers (2821) 3 Total Capacity: Z" gallons Product Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: ER/Tank(2820) ❑ Containers (2821) 4 Total Capacity: u o Product Type: gallons (per tank or cumulative for containers by product type) Install Date: M Tank (2820) ElContainers (2821) #of Containers: TA#:L9 S-7 50 Total Capacity: � b gallons Product Type: � . (per tank or cumulative for containers by product type) Install Date: � Total Capacity this Page: 2 —Z' gallons Total Capacity for Site: �� - ( gallons Comments: q _ C r 7 1_ , EHD Inspector: Reviewed Date:/),I � L By Initial: w�0By Entered Date: Initial: *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