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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: sa /►1 C"'Page of Facility Address: City: 5TO G/G7o Inspection Date: MZW60 223S b-4 u-iVa FA #: PR M (3cj pry-- m Plam nt: I -?-3'® 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. El Tank(2820) ❑Containers (2821) #of Containers: TA#: /9`� Cr / 1 Z Total Capacity: l� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: 2 Total Capacity: �� gallons Product Type: L' %�� C �— 0> l/ (per tank or cumulative for containers by product type) Install Date: WTank (2820) ❑ Containers (2821) #of Containers: TA#: 1��Ai PM 3 Total Capacity: gallons Product Type:LpS� (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#:�i (� 1 Tank (2820) ElContainers (2821) 4 Total Capacity: 0 0 M gallons Product Type: �f,P (per tank or cumulative for containers by product type) Install Date: ank (2820) ElContainers (2821) #of Containers: T #: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 44" gallons Total Capacity for Site: % gallons Comments: z A ry � ' o �b2 v EHD Inspector: Reviewed By Initial: Date: D.1, �°, Entered Date: By Initial: I )/,- v "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