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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: ^ • S Page _� of Facility AddresCity: Inspection Date: 11 l//b?s C,o r7 o L- 457 `0 FA#: / PR M Program Element: 7�o6 P j 28 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. E Tank (2820) ❑ Containers (2821) *of Containers: TA#: P),E j916 7 :a' 1Product Type: o"a_ezz Total Capacity: . ' a00 gallons (per tank or cumulative for containers by product type) Install Date: IV/Tank(2820) ❑ Containers (2821) #of Containers: TA#: 4f 1 29)79 2 Product Type: Total Capacity: I p'dP gallons (per tank or cumulative for containers by product type) Install Date: E7 I Tank (2820) ❑ Containers (2821) #of Containers: TA#: L96 $"O jd 0 3Product Type: min S' Total Capacity: ,� J d gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) L7 Containers (2821) #of Containers: TA#: g D4 I 4 Product Type: AIX—C7-,m D'�l/ Total Capacity: Z-0-e> gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 19"Containers (2821) #of Containers: TA#: h 5 Product Type: /% t�T_� 0 { �' Total Capacity: // � gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 'Z �� gallons Total Capacity for Site: Z gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: l4.lp 01A 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