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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 Na e: /% - Y- Page of Facility Address: City: / o �1 Inspecti n Date: 5 -Z/ FA #: 5-970 PR #: 8 Program EI ent: -zg3V 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. ank (2820) ❑ Containers (2821) #of Containers: TA#: '�5 $!j 1 j Product Type: Total Capacity: Pig gallons (per tank or cumulative for containers by product type) Install Date: E?' rank (2820) ❑ Containers (2821) #of Containers: TA#: � / (9 2 Product Type: DA," Total Capacity: /' � f�� gallons (per tank or cumulative for containers by product type) Install Date: Zk-f 'ank (2820) ❑ Containers (2821) #of Containers: TA#: '�)6 ( $ 37 3 Product Type: �%�i Total Capacity: �� gallons (per tank or cumulative fo containers by product type) Install Date: n Tank (2820) ❑ Containers (2821) #of Containers: TA#: d6-1 `� c3q� 4 Product Type: r1'A S 97 Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: � c e gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: C) (90 gallons Total Capacity for Site: � � / D 0 gallons Comments: EHD Inspector: _ By Initial: w�v (cl- Reviewed`1 Date: ]!By ntered Date:_ Initial:to *Aboveground storage tank means a tank that has the capacity to store 55 gallons or mor of petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08