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SAN JOAQUIN COUNTY �I • • 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:/ Page of Facility Address:C 22,� �� City: Inspe�o � tQ m� FA #: PIR M Program Element 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#: 1 Total Capacity: gallons Product Type: �� (per tank or cumulative for containers by product type) Install Date: VTank (2820) El Containers (2821) #of Containers: 'fA#: _ fZ 2 Total Capacity: �Ot% gallons Y Product Type: (per tank or cumulative for containers by product type) Install Date: q,"/rank (2820) ❑ Containers (2821) #of Containers: TA#: /951 � �gCv D 3 Total Capacity: .� � gallons Product Type: pfi S (per tank or cumulative for containers by product type) Install Date: an(2820) ❑Containers (2821) #of Containers: ` T i 1 g h 4 g Total Capacity:�� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 G'� Product Type: Total Capacity: ,� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: z gallons Total Capacity for Site: t' gallons Comments: EHD Inspector: Reviewed Date: By Initial: '� ,'ljl • 01 Entered By Initial: Date: g 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