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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: a !- o 7- l ✓ r � ? � —/, Page � of _ Facility Address: City: Inspection Date: 2 _57 N c J4 CAM FA#: PR#: Program Eleme t: 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 Total Capacity: b-d gallons Product Type: a� (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: /75-1� 2Product Type: __�04, Total Capacity: 1 gallons (per tank or cumulative for containers by product type) Install Date: 2 Tank (2820) ElContainers (2821) #of Containers: TA#: aSI $rJ�s 3gallons Product Type: Total Capacity: (per tank or cumulative for containers by product type) Install Date: ✓ D ank (2820) ❑ Containers (2821) #of Containers: TA#: /-9� �O 4 Total Capacity: d p gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: TA#: 5Product Type: Total Capacity: " gallons (per tank or cumulative for containers by product type) Install DatP- Total Capacity this Page: Z 3 r gallons Total Capacity for Site: Z �f gallons Comments: EHD Inspector: Reviewed Date: Entered Dat LBy Initial: L. o /1. •0� By Initial: O "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleuni "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08