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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: d3 � b/N 0 19 -5 /--A Page of Facility Address:City: Inspection ate - FA #: X`7Sa PR #: Program Element: 2,,?3p 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#:7 1Total Capacity: Product Type: � gallons r (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 3 2 j) Product Type: Total Capacity: % gallons (per tank or cumulative for containers by product type) Install Date: 3 ank (2820) ❑ Containers (2821) #of Containers: 1jTA#: Total Capacity: gallons Product Type:-7za:w� (per tank or cumulative or containers by product type) Install Date: #of Containers: �� TA#: ❑ Tank 3'60ntainers (2820) (2821) 4 Total Capacity: gallons Product Type: �A& W (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ontainers (2821) #of Containers TA#: c� 5 Product Type: 1V %/1' 1/ Total Capacity: / gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: - EHD Inspector: Date: +� Reviewedt wI �,� By Initial: Wv -1. � 1 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