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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: _ �, C�j/ll/� �j /-Ri 1:�- A/512S /NC/ Page of -- Facility Addressn:�] [' / City: Inspection Date: �} FA #: PR #: Program EI ment: J � Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks` and containers". Complete one box for each tank or each cumulative container product type. #of Containers: TA#: �� / [7i/Tank (2820) 11 Containers (2821) 1Total Ca acit �� Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: 2/Tank(2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: � (I �j. gallons (per tank or cumulative for containers by product type) Install Date: L:�Tank (2820) ❑ Containers (2821) #of Containers: _ TA#: /957$/q/'"97 3 Product Type Total Capacity: �� i� gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: I g [I/Tank ElContainers (2820) (2821) 4 Total Capacity: = ( gallons Product Type. (per tank or cumulative for containers by product type) Install Date: �ank (2820) ❑ Containers (2821) #of Containers: TA#: �.� / �P7C 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: j D gallons Total Capacity for Site: / gallons Comments: EHD Inspector: Reviewed Date: By Initial: VA 00. 01�) Entered Date: By Initial: 'y/ � /'� zi "`Aboveground storage tank eans 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. 7 EHD 28-01 AST SURVEY FORM 09/12/08