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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: „ z 1,9005 Page � of Facility Address: City: Inspectio Date:ryry /� -� T� 7j ` ��Zi V, FA #: PR M p3 Program Element: Z Tank/Container Information Complete for all sites with cuprulative aboveground storage of petroleum ?1,320 gallons in tanks* and containers**. Com I e one box for each tank or each cumulative container product type. rank (2820) Containers (2821) #of Containers: TA#: 1 Total Capacity: Z-00 gallons Product Type: Gri/,l STC al(/ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total 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: Iz- 0-&-9 gallons Total Capacity for Site: gallons Comments: EHD Inspector: P-6 h - 6 Reviewed Date: By Initial: Entered Date- ate: By Initial: D *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