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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: E Page % of '2(7- 44-Jr `Y Facility Address: Cit : Inspection Date: i o 3 o 1 r� C0 n a o 1,I's- 4L o �7 �0 FA#: R#: [t.3�s Program Element: 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1Product Type: Total Capacity: /<j 0 d gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: 2 Tank (2820) ❑ Containers (2821) 2 Total Capacity: , ® � gallons Product Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: 6 a 1:1 Tank (2820) Cntainers (2821) �r 3 gallons Product Type: rte, G Total Capacity: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) E9 Containers (2821) #of Containers: '�'`� TA#: 65J2 2 at�42 4 Total Capacity: gallons Product Type: _ d 0 671 t/ (per tank or cumulative for corftainbrs by product type) Install Date: ElTank (2820) Containers (2821) #of Containers: TA#: Bc5 t ; o? 7 5 Product Type: �� A -1 L C) t Total Capacity: s gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Pat P gallons Total Capacity for Site: © gallons Comments: EHD Inspector: _ Reviewed Date: Entered Date: By Initial: �. y•�� V I By Initial: f.[ *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