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SAN JOAQUIN COUNTY ti 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: ��=S 7-' b70-4,57' /Yn � `4/f,41/, age / of / Facility Address: �� City: Inspec•on a : Z q - A��AIA 15-T /q CO� /1��/ 0 FA#: PR#: Program Element. DDS iq zS3o FA#: —T 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) El Containers (2821) #of Containers: TA#: 0,57 1 Product Type: 141-41 r'f`G Total Capacity: 300 gallons (per tank or cumulative for containers by product type) Install Date: Xank (2820) ❑ Containers (2821) #of Containers: TA#: 1 - 7 2 � Product Type: Total Capacity: / gallons (per tank or cumulative for containers by product type) Install Date: E Tank (2820) El Containers (2821) #of Containers: / TA#: b,S 1`7'� l $� 3 Product T C��S Total Capacity: �d"� gallons Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Containers (2821) #of Containers: f TA#: 7 9 4 Product Type: /17 0;701—' Di 61 Total Capacity: 5.5 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) econtainers (2821) #of Containers: TA#: ,'�-1-79,90 5 Product Type: 11111plc/'ll o Total Capacity: // � gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: l01 (0-5— gallons Comments: j3j/A Al /v Z,,A ;= r .s-3 0 o2 20 Z 4/ EHD Inspector: TBByInitial: eviewed _ ` Date: Entered Date: ` ' -of 2 S By Initial: Yf l— [b `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