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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page L( of L Facility Address: City: Inspection Date: c FA M PR M Progr Element: 00 Z-,F<3 I--? I z 3-2-- Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum>_1,320 gallons in tanks'and containers". Complete one box for each tank or each cumulative container product type. [Tank (2820) ❑ Containers (2821) #of Containers: TA#: 16 Product Type: k. 0. .J ,-4(fc I – 150 4'- 191,�L_ Total Capacity: ?,—_ gallons [ (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: a�lv 2 Total Capacity: )?jam gallons Product Type: (per tank or cumulative for containers by product type) motBC-001, Tank (2820) ❑ Containers (2821) #of Containers: TA#: 05Qj0 1, 3 Product Type: 1^✓.,�rA lie, c?,1— �5v -rte &r4 L, Total Capacity: ��15 gallons (per tank or cumulative for containers by product type) Install Date: Ei/Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9h PL,Oei2� 4l Product Type: � 4,�,,-hc, O �— c,�—Lim. DMI Total Capacity: /41 I7 gallons (per tank or cumulative for containers by product type) Install Date: [Tank (2820) ❑ Containers (2821) #of Containers: TA#: _6,2,9&' S 56 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: -2 gallons Total Capacity for Site: gallons Comments: A 61 EHD In ec r: Reviewed . ( Dat Entered Date: By Initial: V By Initial: r " veground 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 REV 04/19/12 AST SURVEY FORM