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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: O �r rl d l'J S Page of Facility Address: � r � City: InVeotioDge: TA FA FA#: 3 ( (, 3 � PR#: Programlment: D5a g' Lam' ��0022 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. Kank (2820) ❑ Containers (2821) #of Containers: STA#: 1gallons Product Type: �� Total Capacity: (per tank or cumulative for co niers by product type) Install Date: VTank (2820) ❑ Containers (2821) #of Containers: TA#: /7 '9-'FrT 2Product Type: ' Total Capacity: S gallons (per tank or cumulative for containers by product type) Install Date: L4�t/ F� ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (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: f 7 5c�lj gallons Total Capacity for Sit, /* Q�1 gallons Comments: EHD Inspector: -, ReviewedDate: Entered Date: By Initial: VA 1) -5- v� 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