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` go SAN JOAQUIN COUNTY so 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 Na ;. Pae t of mp _ F P- k- Facility Facility Address: City: Inspecti n D nto, FA#: PR M Program Element: 57 0531)5 -z-S3 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& nk (2820) ❑ Containers (2821) #of Containers: TA#: a,-6-f Q V/l�) 1 Total Capacity: 1'2015'd gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 LT' S p Total Capacity: -) (9-Z17 gallons (per tank or cumulative for containers by product type) Install Date: r _� BS'1 qD I aZ I"ank (2820) Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: Z c& gallons (per tank or cumulative for containers by product type) Install Date: MTank (2820) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: �U-� 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: Z r� S EHD Inspector: Reviewed Date: Entered Date: By Initial: t� �.a�.� By Initial: kv // m . e `Aboveground storage tank means a tank that has the capacity to store 55 gallons or ore f petroleum *"Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08