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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 Facilit Name: r r 0 vi C n '�� . Page of Facility Address: City: Insp ction ate: )0 Ga FA #: PR #: Pro ram Element: 7 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, l Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: Ola b gallons 1 Product Type: f 7 c) 66 q -J h 9-0 IWO-- tank or cumulative for corlitainers by product type) Install Date: I �I Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: p y: gallons Product Type:,�/� (per tank or cumulative for con ainers y product type) Install Date: IL— El Tank (2820) gContainers (2821) #of Containers: ( TA#: 3 Capacity: Total y: gallons p Product Type: (per tank or cumulative for contaliTTers by product type) Install Date: ❑ Tank (2820) �< Containers (2821) #of Containers: 1 TA#: psi 4Product Total Capacity: � gallons Type: New 012— . (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: D gallons Total Capacity for Site: o gallons Comments: EHD Inspector: Reviewed Date: By Initial: `_ �.) (, Entered Date: By Initial: C / 0?;// PC/ .,, J wu � awiaya Cahn [HeEil15 a tdf]K Ulat nas the capacity to store bb gallons or more of petroleum.' **Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM