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If SAN JOAQUIN COUNTY ~ or 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 12z s- Facility Address: 2 RO City: l Inspec on D te:�, ��'O Z FA #: FIR#: o ProgramElement: -2-y3p Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks` and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9,5 19'5,5'` 1 So Product Type: r Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: T : /6-1 2 Total Capacity: gallons Product Type: (per tank or cumulative for c ntainers by product type) Install Date: 0 -Tank (2820) Containers (2821) #of Containers: TA#: �� k`1'S 3 Total Capacity: �� gallons Product Type: G��%1% Ta 01 (per tank or cumulative for containers by product type) Install Date: #of Containers: TAA#: ❑ Tank (2820) Containers (2821) 4 l Total Capacity:—,� V gallons Product Type: (per tank or cumulative for containers by product type) Install Date: [!Tank (2820) ❑ Containers (2821) #of Containers: TA#: Type: �✓ s �� r f � 5Product Total Capacity: �% gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 5 57zv gallons Total Capacity for Site: j 0'0 gallons Comments: A/ jD -5-A14 2� '�4Y3-- 5-V o(� D EHD Inspector: f Reviewed By Initial: Date: I (, C� - p� Entered Date://,/, By Initial: �Q "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