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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: c d l--9 A ArC,9 Page of Facility Address: . Cit : Inspection ate• i `� 30 1 S• 0 �2/ on/ /7 FA#: PR#: Progra Element: 3 Z t 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#: , �� 7 1Product Type: 4-2��z , Total Capacity: 6P-0'0 gallons (per tank or cumulative for containers by product type) Install Date: 111�T ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 2 �� Product Type: Total Capacity: FS� gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: 9,6 /f027 3 3 Product Type: --� Total Capacity: �— gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) L7 Containers (2821) #of Containers: j TA#: 4 Product Type: Total Capacity: .j� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (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: gallons Total Capacity for Site: gallons Comments: A`oo 9 �e,o fir �. EHD Inspector: n Reviewed Date: Entered Date: l— By Initial: lC6 By Initial: *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