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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 � t - 7 7, � ��l ,T Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Faci Pity Name: /i11 -7r ✓TA/y � — Pageof � P1 Facility Address: ty: Inspection ate: FA #: PR M 3 P Program Ele ent: 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. Eir Tank (2820) El Containers (2821) #of Containers: TA#: D5-1 7 �� 1 y �% Product Type: ✓� Total Capacity: % O gallons (per tank or cumulative for containers by product type) Install Date: l/-ank (2820) ❑ Containers (2821) #of Containers: TA#:A-51-766;:,Z 2 Product Type: 6Y 1_ Total Capacity: % � aO gallons (per tank or cumulative for containers by product type) Install Date: ❑ 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 Total Capacity: 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: 2 �,, �+, �i gallons Total Capacity for Site: 7r M-e-�-o gallons Comments: EHD Inspector:Reviewed �* > Date: By Initial: p Entered Date: By Initial: I �, *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 09/12/08 LWA AST SURVEY FORM