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{ r� 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 tj 0i1 G l l �'� Page of Facility Address: City: Inspection Date: FA#: PR M Program Element: '72� g � 8 30 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. 2 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 6161 91P 7 5- 1Product Type: T 'P4.y Total Capacity: 19 C-9 gallons (per tank or cumulative for containers by product type) Install Date: 2/Tank (2820) ❑ Containers (2821) #of Containers: TA#: b 51 a Q 7 2 Product Type: Total Capacity: FO gallons (per tank or cumulative for containers by product type) Install Date: V/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 0,5_1 06 3Product Type: F6j Total Capacity: 7— Y-0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (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: j gallons Total Capacity for Site: 0 gallons Comments: EHD Inspector: Reviewed Date: Entered / /-t Date: By Initial: VA4 By Initial: /��✓X/ / Gr QI 6 *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