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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: _ Cj `.S fill �� /✓ C- Page Z of T Facility Address: City: 00 Ic 0 S TA �'f C- � �� Inspecti7�ly /0 to - FA #: PR #: Program Element- -2- 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. El Tank(2820) C7 Containers (2821) #of Containers: TA#: 1 r Total Capacity: • D gallons Product Type: /� —� (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 0 Containers (2821) #of Containers: �� TA#: Total Capacity: �/ �/ gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) D Containers (2821) #of Containers: f TA#: 3 r' Total Capacity: i gallons Product Type: (per tank or cumulative for containers b� y 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: -2- 2 b gallons Total Capacity for Site: gallons Comments: EHD Inspector:> Reviewed Date: Entered Date: By Initial: By Initial: O y [ *Ahnvanrniinrl c+nrnnc f-1, .., 4---1, �r.._. �__ � '----y'-- —,-+J� ac I� I IGGII IJ Q lG1m Ll 10L nas Me capacity to store 55 gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM