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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 FIRM Facility Name: 1',�r /► //2 Page L of Facility Addr s: City: Inspect' n D,It ir FA#: PR#: Progra Elei ent! Q 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! Tank (2820) ❑ Containers (2821) #of Containers: TA#: D D l _ 1r Total Capacity: j - a gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: l•5 2 �'� Product Type: 1✓� Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: f///--��l� Total Capacity: ,�� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Rdontainers (2821) #of Containers: TA#: B 4 - e: Total Capacity: „S � 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 19 5 Comments: lLt X74 -' s9riv fit er EHD Inspector: Reviewed Date: �` Entered Mite: By Initial: �6 , By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleui . **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08