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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: Page --,/ of 71 Facility Address: City:nspection Date: (� z"' a/UC FA #: l PR M Program Element: 05 1a z 83d 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. Tank (2820) ❑Containers (2821) #of Containers: TA#: Del D 1 d � Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ±r ---Tank (2820) El Containers (2821) #of Containers: TA#: /26 ) $ aff I 2 Total Capacity: o d gallons Product Type: (per tank or cumulative for containers by product type) Install Date: EA/Tank (2820) ❑ Containers (2821) #of Containers: TA#: �5 a 3S� &0 Product Type: LV l4 5 Cl Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: L�Tank (2820) ❑ Containers (2821) #of Containers: TAS #: D115 -I S- 4 Total Capacity: >� d o gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA : /9J1 STC? 5 Total Capacity: Lj 0-A6gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z 500 gallons Total Capacity for Site: -Z (2 gallons Comments: 5 EHD Inspector: n C,L Reviewed Date: By Initial: "yfp Entered Date: By Initial:VIP 5 1 *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