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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: A /55- 11l /V A / Page of ___Z Facility Address: c City: Inspec ion to:/ Z s yr 1z. /-Ft-/6 s/ S� 0 FA #: 1�3� PR #: o5 ZL2 Program Element: 1 -2- 11 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks* and containers**. 11) Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: IoOO gallons Product Type: (per tank or cumulative for c stainers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2Total Capacity: 5r) gallons � Product Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: Tank (2820) ❑ Containers (2821) 3 Total Capacity: 1-3 b D gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) IE/Containers (2821) #of Containers:y TA#: J 4Product Total Capacity: % gallons Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: 5 Total Capacity: 3 6-0 gallons Product Type: I/I/ /q STS Q � (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 3 �� gallons Total Capacity for Site: 3 J gallons Comments: EHD Inspector: ; 7eviewed ' Initial: Date: �.n) 14,E Entered Da2LJ 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 09/12/08