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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: / f 0 A G– W 1q L--� U izr, %�,o , Page ,a of -J--- Facility Address:�r City: Inspection Da Z Z� Ofl /v ' % FA #: PR M 7 '7 5 -30 o Progr6m Element: Z W 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: TW k - $ % 1 r Total Capacity: > o-0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Ld�l ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type:, (per tank or cumulative for containers by product type) Install Date: L -Tank (2820) ❑ Containers (2821) #of Containers: TA#: !9,'Tt $ jkel? 3Product Total Capacity: tlt-' gallons Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) El 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#: d 5 Product Type: 14,14 / 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: �, Reviewed Date: By Initial: VA� Entered Date: By Initial: rJ *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