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ti 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: 0 A/ Page / of Facility Address: city^j � � Inspection at tt S� vy FA#: PR M Program Element: 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. E?zTank (2820) ElContainers (2821) #of Containers: T/ #: � 1 Total Capacity: �0� gallons Product Type: 4� (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 6 2 Product Type: /—'i✓ Total Capacity: gallons —� (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 9h 'Z3 �J 3 Total Capacity: ✓J—,/) gallons Product Type: (per tank or cumulative for containers by product type) Install Date: LTJ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 all Product Type: Total Capacity: T B 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: fj gallons I Total Capacity for Site: 177 G) gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: �,' t"3p By Initial: ago *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