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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: CAIIAe4C ,r Page `— of Z! Facility Address: V �^ City: Inspectio Date•, FA #: PR M Program Element: 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) Containers (2821) #of Containers: / TA#: 1 Total Capacity: h 15—gallons Product Type: SVA; Zk r),-- l.. (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: h 611 / 2 — i Product Type: �-7�1 TO Iv—, pf L� Total Capacity: � .� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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 Total Capacity: p y: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page:Zzo gallons Total Capacity for Site: gallons Comments: EHD Inspector: \ Reviewed Date:Entered By Initial: Date: By Initial: fi 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