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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 ENe: / 007 A fVc C 5 Page of Facility Address: City: Inspection Date* 1pe 2 A/ FA#: PR#: I Program Ele ent: _ v d 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. Tank (2820) ❑ Containers (2821) #of Containers: TA 9 073 1 Product Type: Total Capacity: gallons (per tank or cumulative for containerrby product type) Install Date: OZ Tank (2820) ❑ Containers (2821) #of Containers: TA#: D5) 2 Product Type: Y� Total Capacity: gallons (per tank cumulative for containers15y product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: i TA#' 3 Total Capacity: 0 170 gallons Product Type: (per tank or cumulative tdr containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: (�u�lgo7(37 4 Product Type: Al Total Capacity: j t� gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: /�I 14a 3� 5 Total Capacity: _� gallons Product Type: j2r /r �r/ L (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z6 gallons Total Capacity for Site: gallons Comments: 3T a - (714 D 0— EHD Inspector: Reviewed Date: Entered Date: By Initial: �.�b' By Initial: T/I-1112 *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