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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: •7'T�r- � ✓o � Page of Facility Address: �� / _/ City: Inspect' n Date• FA#: PR M 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. E9- ank (2820) ❑ Containers (2821) *of Containers: TA#: '7 5?Al Ir 1 Product Type: „42,4,2 .,g p Total Capacity: Prp gallons (per tank or cumulative for containers by product type) Install Date: I1"Tank (2820) ❑ Containers (2821) #of Containers: TA#: 06-) 2 � � Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Wank (2820) ❑ Containers (2821) #of Containers: TA#: 15 61 3 Product Type: �Y/� O Total Capacity: gallons (per tank or cumulative for con ainers by product type) Install Date: M/Tank (2820) El Containers (2821) #of Containers: TA#:: &96- 4 C"gallons Product Type: Total Capacity: S (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: ,T,A-#_: n(9 6-)?'r D 5 Product Type: �.•�•�� Total Capacity: .3 ov gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 0gallons Total Capacity for Site: -Z'r JA gallons Comments: EHD Inspector: ReviewedDate: Entered Date: V By Initial: VA By Initial: ':q-f !Z D *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