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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: 'r Page --4—of Facility Address: City: Inspection 2Z Z Q FA #: J 26 PR M 06cv-q 7 5<F I Program lem nt: Z 9 0 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks` and containers"*. Complete one box for each tank or each cumulative container product t o ❑ Tank (2820) ❑ Containers (2821) #of Containers: 1 Total Capacity: 3 S gallons Product Type: �Z2✓t�.-� (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: �l $ ��B 2 Product Type: Zz'Lp 161 Total Capacity: 0-�2 D gallons (per tank r- cumulative for containers by product type) Install Date: L,44� Tank (2820) 18Containers (2821) #of Containers: � TA#: o 3 Total Capacity: /) 0 gallons Product Type: _ 1,9 (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: ❑ Tank (2820) U�-G/ontainers (2821) 4Total v Product Type: � Capacity: % gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: � gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: V_ABy Initial: �i •'�, 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 09/12/08