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' I 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: k6:10 Page ' of Facility Address: City: Inspection Date: CON S ToCA Mrs'v - n FA#: I R M Program Element: 17 1Cr .-Z- 3 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. Elk Tank (2820) ❑ Containers (2821) #of Containers: TA#_ 1 � Product Type: Aj ice Total Capacity: � gallons AJ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: gallons Total Capacity for Site: ®� gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: t{-l � By Initial: / �( /� D *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. C **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08