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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: .� 6%'j-lil G� Q�f i— �% C Page 2 of Facility Address: 5o City: s��o Inspectio Date: FA #: Pik #: 05-:2a/ -7D Program Element: 'P'F�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. ❑ Tank (2820) 'Containers (2821) #of Containers: 02 TA#: O 5� 1 1 Total Capacity: 1/0 gallons Product Type: �� O (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: �_ TA#: 2P Total Capacity: �J CJ gallons rod uct Type: 13r (' 4M& _&45;j (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Xcontainers (2821) #of Containers: TA#: 3 Total Capacity: /00 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ �Dntainers #of Containers: c5j;? TA#: Tank (2820) (2821) 4 Total Capacity: /a / O gallons Product Type: AAoi r O/ (per tank or cumulative for containers by product type) Install Date. - ate:❑ ElTank (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:/C 5 gallons Total Capacity for Site: a gallons Comments: EHD Insp tor: Reviewed Date: B Initial: i,'.� I By r �, Entered Date: By Initial: /&' *Abov gro drstorage tank means k that has the capacity to store 55 gallons or more of petroleum. ` **ConWP6r means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08