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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: ,,12 % N G Page of Facility Address: City: Inspection Date: ® S /✓i At 1y� -- --2 — C 11 FA#: PR M Program lement: 705-2- � a � `N3� 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 : 1 Total Capacity: t Q d7 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: DY ank-(2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: Product Type: /Es � D7 gallons (per tank or cumulative for containers by product type) Install Date: k (2820) El (2821) #of Containers: TA#: 6),b l-7an7 4 Total Capacity: 2� gallons Product Type: (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: Z� gallons Comments: EHD Inspector: Reviewed , , �1 Date: Entered Date: C—, By Initial: W'v c�. By Initial: a 0 "'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