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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: Aa/11 14ZI ® Page Facility Address: ci"Tl,'� 6 6'c v- ��i�� 2.TS lu Inspection Date- ate: j _ FA #: PR 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. El Tank(2820) LY�Containers (2821) #of Containers: TA#: 1 Total Capacity: Z' /�? gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820)Containers (2821) #of Containers: TA#: 2 Product Type: ZZ Y/I`'>� In ��"� l� Total Capacity: � 21� gallons (per tank or cumulative for containers by product type) Install Date: El Tank(2820) CCI ontainers (2821) #of Containers: _� TA#: 3 Product Type: 4g,Total Capacity: / 7iO gallons (per tank or cumulative for containers by product type) Install Date: ❑ #of Containers: TA#: L,Containers Tank (2820) (2821) _ 4Z� Total Capacity: � —gallons Product Type: Z all C r P,� r/ �J (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ontainers (2821) #of Containers: ^� TA#: 5 Total Capacity: �% gallons Product Type: (per tank or cumulative for c6ntafners by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector:' Reviewed Date: By Initial: Entered Date: By Initial: a Q Hoovegrouno 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