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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: SAN 01� Aboveground C- Page Z of 'Y Facility Address:�• City: fiD , T� Inspecti n Date• i i3 7V FA #: PR #: 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#: 6 1 Product Type: /7/ O r• A Cl C,, Total Capacity: _lrJ gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: / TA#: �� 3�02 20 r Total Capacity: S -> gallons Product Type: — 01 o () rte. lV t (per tank or cumulative for containers by product type) Install Date: e Tank (2820) ❑ Containers (2821) #of Containers: TA#: Q 3Product Total Capacity: C) 0 gallons Type: 11),4 C (lam (( / (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: p y: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: p y: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: / gallons Total Capacity for Site: gallons Comments: EHD Inspector:�2 Reviewed By Initial: Date: ---TEntered By Initial: Date6w/- *A� �.. _- -- 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 09/12/08 AST SURVEY FORM