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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: —�- _ r to N S Page _of Facility Address: City: Inspection Date: C �> " � ' FA#: PR#: ProgramElement: 00 5a �� 2 5 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. R-Ta k (2820) ElContainers (2821) #of Containers: TA#` 9 1 Product Type: Total Capacity: 3 r' �' �� gallons (per tank or cumulative for containers by product type) Install Date: P Tank (2820) ❑ Containers (2821) #of Containers: ?T,A#: 2 �' Product Type: 1�c,1•�.r Total Capacity: � (?� gallons (per tank or cumulative for containers by product type) Install Date: L9'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: a c) gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: J^ 4 , n� Product Type: Total Capacity: L gallons (per tank or cumulative for containers by product type) Install Date: 2 Tank (2820) ❑ Containers (2821) #of Containers: TA#: r r- /-) 5 Total Capacity: gallons �� Product Type: it j '� (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: o P) 0 gallons Comments: EHD Inspector: � Reviewed Date: Entered Date: By Initial: L{•56.0 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