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R 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 L p )4 Page of Facility Address: ity: Inspection gat e: �0 _ 1 J- M /C-� /� � 2 7�D FA C PR#: Program Element- 17o33 lement:17oS3 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#: 1 Product Type: Total Capacity: /'pb � gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: 2 Total Capacity: 5 e gallons Product Type: (per tank or cumulative for containers by product type) Install Date: /9�:-Del Tank (2820) ❑ Containers (2821) #of Containers: TAA#: /0, 1 S' 3 Total Capacity: a 6i-e) gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: TA#: �u`Io2 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#- 6 6-17-c3-a6- 5 Total Capacity: �� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 3 / 00 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: �,'�l-� By IloInitial: kz "'Aboveground storage tank means a tank that has the capacity to store 55 g ns or more of petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08