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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: �r6Ott i 6 00 'F (OU4 t 6'( Page --- of-- Facility Address: City: Inspection Date: ? ( -� 4 P ror 0�� FA#: PR#: Program Element: x013 2 9 3 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#: ; / r ; 1 Total y: gallons Capacity: 608 Product Type: b / gam, p (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: ,�j) 2 Total Capacity: Y66 gallons ProductType: n y-9, Q (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers 2821) #of Containers: TA#: / 3 0� Product Type: Total Capacity: Ilons (per tank orcumulativ for ontainersbyproduc pe) Install Date: El Tank (2820) Product Type: t`t'Containers (2821) #of Containers: 'P;,-f TA#: /`?�) 4 qS�a -Qr��L ill Total Capacity: (1 ® gallons - (pertankorcum tivefercontatnersbyproducttype) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 5 Product Type: K!' Total Capacit gallons (per cumulative for containers byproduct type Install Date: Total Capacity this Page: gallons Total Capacity for Site: allons Comments: 6a° a i � EHD In Reviewed Date: Entered 1 /! Date: % By Initial: By Initial: ! 1 "Abovegrou d storage tank means a tank that has the capacity to store 55 ga Ions or more of petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08