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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: _ t�Iapt �r /�/� �� •! l _ Page --L of Facility Address: C Inspect on D FA#: PR#: 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. ET Tank (2820) El Containers (2821) #of Containers TA#: 1 Total Capacity: / ('� gallons Type: 11i (per tank or cumulativefof Containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: � Product Type: e/ �/ allons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) L�1 Containers (2821) #of Containers: / TA#: /�'S( $ Zg 3 Total Capacity: r Product Type: � gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) LJ'Containers (2821) #of Containers: 5 TA#: L5:1,?� 7 4 Product Type: r�h 7��- -7 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) L� Containers (2821) #of Containers: / TA#: 0S( 2 5 Capacity: � Product Type: Total Ca y: � 3 gallons ✓�' °�%��'�� p (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page:--, gallons Total Capacity for Site: -2, S gallons Comments: EHD Inspector: Reviewed Date: Entered Date: L r By Initial: VIN U_ (� By Initial: i O *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of pe roleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/1?/09