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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: /� d Sp .P1 kn g 4 Page 2 of Facility Address: b S A G 1C. Ci y: 16 VF Inspection Date: '7'/7`_ FA #: !6'93 PR #: 05_3o,�,o Program Element: �Z_83D Tank/Container Information Complete lative aboveground storage of petroleum 21,320 gallons in tanks* and containers**. Complete one box h tank or each cumulative container product type. ❑Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 apacity: gallons Product Type: (perta . �GQPt2q a Install Date: TO 7_4'; kV A "1�1/ Ell/Tank #of Containers: TA#: ank (2820) ❑ Containers (2821) 2 Total Capacit � ga Ions Product Type: a (per n or cumulative for contai ers by product type) Install Date: 0 Tank (2820) ❑ Containers (2821) #of Containers: TA#: S'7 3 Total Capacity: 0 0 gallons Product Type - (per tank or cumulative for containers by product type) Install Date: M Tank (2820) ElContainers (2821) #of Containers: TA#: I b w< g 7 4 � 0 0 p _ Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: .% Tank (2820) El Containers (2821) #of Containers: TA#: 5 - ' Total Capacity: G v 0 __gallons Product Type: (per tank or cumulative fcr eo rs y product type) -- -- — Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: By Initial: Entered Date: By 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 09/19/08