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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: S R—' �`r 2✓�, tiG, Page of Facility Address* Inspectio77V6i FA#: PR M Program EI a t: Z , �' 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#: 65-12 '7 1 Product Type: ��}lZ., LI C,�-j � ti 4— Total Capacity: �.ontwn.rby gallons (per tank or cumulative ft type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: 2 gallons Comments: EHD Ins tor: Reviewed Date: Entered !at : Un r � By Initial: By Initial:"A ovegroun storage tank means a tank that has the capacity to store 55 gallons or more ofpetrole ""Container means a storage device designed to be moved when full. EHD 28-01 09!12/08 AST SURVEY FORM