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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: �. 1:5rr r`� �- Page __/_ of Facility Address: City: Inspect* n Da FA#: PR#: Program Elem n : Tank/Container Inforniation Complete for all sites with cumulative aboveground storage of petroleum 2_1,320 gallons in tanks`and containers`*. Complete one box for each tank or each cumulative container product type. IO/Tank (2820) ❑ Containers (2821) #of Containers: A#: 05J7 7� 1 Product Type: Ql~y Total Capacity: E) �'� gallons yp �� (per tank or cumulative for containers by product type) Install Date: /Tank (2820) ElContainers (2821) #of Containers: T ) Z2 all Total Capacity: � gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: I G gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered I Date: By Initial: t .�'� ' By Initial: flW A�Ae "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