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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: / ,, f— r; 4 S Page of Facility Address; City: Ins p ction gate: FA#: n PR#: Program Element: Du 2�,�3 0 Tank/Container Information 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. ❑ Tank (2820) ❑ Containers (2821) #of Containers: �A#: 05/ 7 SSD 7 1 Product Type: o"'_" ) Total Capacity: gallons (per tank or cumulative fo containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: e,5) `7S0S 2 Product Type: � r Total Capacity: �r� gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: jf,h/ '3192 3 ! Product Type: Total Capacity: j gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: P A 4 r- Product Type: �'��' Total Capacity: � � gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0v 5 Product Type: Total Capacity: /'0 0 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: V gallons Total Capacity for S'= 3 �� ©� gallons Comments: o�- EHD Inspector: ReviewedDate: Entered Date: L> �� r By Initial: By Initial: n '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