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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• o m y Page 1 of Facility Address: C Cit •z -o 6 o c, Inspe i Dat FA #: d 1 PR M 1 Progra Element: I 2iy 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#:(p 1 3 C) C) 0 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: 2 /Tank(2820) ❑ Containers (2821) #of Containers: TA#: 126-112 70 0,4.yai) Product Type: Total Capacity: � S 0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers:4— TA#: B �{ 3 C C Product Type: ,b// rr1 -� d% Total Capacity: D gallons (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: By Initial: L1'd� Entered Date: By Initial: a� '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