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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT J 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: / f'7 • S 0 0 Page of Facility Address: I T , City: AIS 0 -AMM Inspect' n Date -/ o 9 FA #: J6737 PR M 05 a leIV7 Program Element: 2 8 30 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. 51-'T'ank (2820) ❑Containers (2821) #of Containers: TA # - 1 Total Capacity: 5© 0 gallons Product Type: ra � (per tank or cumulative for containers by product type) Install Date: M//Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: -r / J 09 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 0 8 3 2 & Product Type: en,� 1-7 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: Z Q gallons Total Capacity for Site: gallons Comments: EHD Inspector:�� ' Reviewed Date: By Initial: .v -01A Entered Date: By Initial: i� 9 *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