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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: 0 � 1iz ,� V�, 'D o Page of Facility Address: City: Inspec 'on Dat 2 S, ` c co TT o FA #: PR M Program E e ent: �L 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. Lr-T'ank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: gallons —94 -- (per tank or cumulative fbr con iners by procTuct type) Install Date: Tank (2820) El Containers (2821) #of Containers/� 51 �p�� 2 Total Capacity: S D�) gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3�Rf Product Type: Y 2 �H Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: Doh 1 tJD ElTank (2820) Containers (2821) 4 Product Type: /,t//4C) S �� l/ Total Capacity: � gallons (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: �/ 0 s gallons Total Capacity for Site: �J d --T" gallons Comments: Z EHD Inspector: Reviewed Date: � T )� By Initial:vv Entered Date: By Initial:kz a *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