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` M 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: i / ' , Y Page of C a Facility Address: City: Inspe top D NC 2Slog FA #: YR #: Program Element: % 4 Q 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. a !tank (2820) El Containers (2821) #of Containers: TA#: D5-,LR''� ,z f 1 Product Type: ol—_ R,f Total Capacity: —5-.120_ gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: Product Type: gallons (per tank or cumulative for containers by product type) Install Date: Lt�Tank(2820) ❑ Containers (2821) #of Containers: TA#: 19 'Iq l' 01.3 3 Y�� Product Type: .�� Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: �, ElTank (2820) qt 6tainers (2821) #of Containers: TA#: 02 4 o Product Type: %� Z) 0 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: El Tank(2820) VaContainers (2821) #of Containers: TA#: 5 / Product Type: Total Capacity: %L� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ' Z gallons Total Capacity for Site: gallons Comments: : " EHD Inspector: Reviewed Date: By Initial: �� ,.�� Entered Date: By Initial: A9 LIJ9 q1 *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. l "*Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08