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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: IJtwt p *x 7 q 5 o S / _ Page of ��K Facility Address: City: Inspection7-7- ate: f o e S 8 � 3 �9 FA#: PR#: Program Element: Tank/Container Information 1S�j 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#: 1 Total Capacity: ZO a d gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: v TA#: 2 Total Capacity: j 62 O 0 () gallons Product Type: i (per tank or cumulative for containers by product type) Install Date: � r LJ'Tank (2820) ElContainers (2821) #of Containers: TA#: Of] ISI 3 -�� Product Type: Z2 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: P`302- 4 `3024 Product Type: �� J C Total Capacity: D gallons (per tank or cumulative for co Miners by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: $—'!J2 5 Product Type: j Total Capacity: � gallons (per tqFR or cumulative for containers by product type) � Install Date: Total Capacity this Page: r (f- �f gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: Lk,a-y�ff+� By Initial: �� D *Abovegrounct 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