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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: 9' A 1� Page of Facility Address: City: I J� - � Inspecti n Da : F77 cid � r FA #: 6 0 P #: I Program Elemen : -'z' zo 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. 1 Tank (2820) ❑ Containers (2821) #of Containers: TA#: x.51 cla� 02 Product Type: Total Capacity: 0 �?o gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: QUI qoZ 23 2 Total Capacity: f 000 gallons Product Type: (A S (per tank or cumulative for containers by product type) Install Date: #of Containers:. TA#: El Tank(2820) 53/containers (2821) 3 -S Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: ❑ Tank (2820) M Containers (2821) 4 Product Type: r//� � % r> 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: gallons Total Capacity for Site: 2% gallons Comments: POXLLAI _6 Zor edz X Z EHD Inspector:Reviewed Date: By Initial: Entered Date: By Initial: jk B *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