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SAN JOAQUIN COUNTY- l� ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd I ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: � -• � � / Page of Facility Address: City: Inspecti 7Dte: FA #: PR M l�3 a9 Program Element: 0 $moo�o 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. � n "" Tank (2820) ❑ Containers (2821) #of Containers: .5) 1 / d 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: C Tank (2820) ElContainers (2821) #of Containers: TA#: 2 r Total Capacity: J gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: _(, h c1 o LP 3 Total Capacity: „� � gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El #of Containers: TA#: Tank(2820) ontainers (2821) —. 4 Total Capacity: 5-) gallons Product Type: /c (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons � Product Type: �' (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: `1. gallons Comments: Ah, P H0'T C' � � R A OM 1 SS /s / 9 3 5 Z 6,0 EHD Inspector: *A4, .A.a...... a _n_ Reviewed By Initial: Date: �G(.1�� Entered Date: By Initial: )r G� rwvvcyivuiw OLVIaye Laa amans a tanK that has the capacity to store 55 gallons or more 6f petroleum. f **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08/08