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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 l ` AS 12 h' (2l2 �� 2U,45`0, Page of Facility Address: City: Inspecti n Dat : tea " c � �A�r � /T; FA#: PR M Program EI ent: q( '?/z/-- 0 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. 2r,"Tank (2820) ❑ Containers (2821) #of Containers: TA#: P 5 I-7 75-0) 1 Product Type: _ J I'P7' 2. 0/ Total Capacity: 2-50 gallons (per tank or cumulative for containers by product type) Install Date: U/Tank (2820) ❑ Containers (2821) #of Containers: TA#: &.5-1-7 76- Product Type: 2 �`f�� L/ Total Capacity: �S� gallons (per tank or cumulative for containers by product type) Install Date: VTank (2820) ❑ Containers (2821) #of Containers: TA#: 7 3 Product Type: (� Total Capacity: LOc?e7 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: �6-/"-2 '7,.t;- 3 4 Total Capacity: /D (} 15'e gallons Product Type: ,�-'r ,Ji�"S�/ (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: t Total Capacity: 0 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 0 gallons Total Capacity for Site: Z© gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: Vj-I By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleu **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08