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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: O D )F ,5 -T Page of Facility Address: U City: C -H i M/ Lr Inspec on t Ia FA #: r�zls PR M a P� Program E'ent: 2� 0 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. L,Tank (2820) El Containers (2821) #of Containers: TA#: g 1 Total Capacity:—) gallons Product Type: 4-1 (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) E•l Containers (2821) #of Containers: TA#: 2 I,Product Type: Total Capacity: l � � gallons (per tank or cumulative for containers by product type) Install Date: LW Tank (2820) ❑ Containers (2821) #of Containers: TA#: /96-/(:B �S q 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ''/ VI-TXank (2820) ❑ Containers (2821) #of Containers: TA#: B"C Ig g'3 E) 4 Product Type: 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: Z v gallons Total Capacity for Site: Z gallons Comments: �� (fir ,x EHD Inspector: Reviewed Date: By Initial: ` p �` '1.��. Entered Date: By Initial: 1,0�� *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. ( t "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08