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` SAN JOAQUIN COUNTY 6 �� ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 1 p Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.org/ehd �� 1�6ou ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 1'✓I rf� L L c j -� Page of Facility Address: City: Inspect*on Da q _ �g d � Z7e: � 0 g FA#: d-1 � c PR#: L © Program Element: Tank/Container Information lL If01 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#: S Q&5- 1 b Product Type: Total Capacity: -! gallons (per tank or cumulative for containers by product type) Install Date: I:yY"Tank (2820) ❑ Containers (2821) #of Containers: / TA#: C,M-1 We?,(Q CP 2 Total Capacity: 'r- ®o gallons Product Type: L/ (per tank or cumulative for containers by product type) Install Date: ErTank (2820) ElContainers (2821) #of Containers: TA#: 3 2,3 C� Product Type: Pili .y Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Zcontainers (2821) #of Containers: TA#: �,Tf R a/Q,F 4 Total Capacity: // 0 gallons Product Type: y (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: . 4/- - TA#: o� 5 Total Capacity: `Z, P gallons Product Type: zv/' (per tank or cumulative for containers by product type) Install Date: Total Capacity this Pag gallons Total Capacity for Site: ��' O Q gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: vl� y.�d-( By Initial r lel� *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