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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: �-�� j 4- 1/0 )VO7 %l �� Page of Facility Address: ity: p Inspectiat/76 0 nn 4 FA#: PR M Program EI 1 -z- Tank/Container 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#: D51<3 1 Product Type: Total Capacity: r��? gallons (per tank or cumulative for containers by product type) Install Date: 0,-Tank (2820) ❑ Containers (2821) #of Containers: QTA#: /96-1 137D142- 2 Product Type: Total Capacity: _ I�� gallons (per tank or cumulative for containers by product type) Install Date: Q ?ank (2820) ❑ Containers (2821) #of Containers: TA#: 06 (g 70.3 3 —�r� Product Type: i=iy' S' Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: D—Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 --��1 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: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ( gallons Total Capacity for Site: j? 7 rl gallons Comments: EHD Inspector: F, Reviewed Date: Entered Date: .�3 By Initial: '1,�, By Initial: ,2�/'*L *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