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~ So 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: / SS Page --of Facility Address: City: Inspec on, Ite: �a v C/.b)q!Z, fi v' " U � FA#: PR M Program ElernAnt: D q 72 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. EO/Tank (2820) ❑ Containers (2821) #of Containers: /� TA#; E) 'P 1 Product Type: �c/ Total Capacity: © © � gallons (per tank or cumulative for containers by product type) Install Date: i 11d Tank (2820) ❑ Containers (2821) #of Containers: TA#: E6:1 Q4j-E) _ 2 C Product Type: Total Capacity: P7-0 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: ` 3 Product Type: Total Capacity: �,�gallons (per tank or cumulative for containers by product type) Install Date: I Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: ��J) Total Capacity: � gallons e (per tank or cumulative for containers by product type) Install Date: r : r'r o' #of Containers: 4 TA#: ❑ Tank (2820) Containers (2821) 5 Total Capacity: S � gallons Product Type: Q�� /�� d (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 'Z gallons Total Capacity for Site: 2 gallons Comments: fel /65. U' 3ozz EHD Inspector: !] Reviewed Date: Entered De te: By Initial: VAp �- By Initial: 7'/0'L? "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleurn. "*Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08