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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: ��, /� S' %i /�/ /'� Page --L of Facility Address: city. Inspection Date: FA #: � PRU�o7 l�"7 Program 1: meot: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. Q Tank (2820) ❑ Containers (2821) #of Containers: _k TA#: 4 5J-7 q'�p 1 Total Capacity: 5 5'0 gallons Product Type:. F'2 z e uk (per tank or cumulative for containers by product type) Install Date: p-�nk (2820) El Containers (2821) #of Containers: TA#:_ 5) '� 5 2 /� Product Type: Total Capacity: �' G n gallons (per tank or cumulative for containers by product type) Install Date: C;I,-Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 t" , Product Type: Total Capacity: = L gallons (per tank or cumulative for containers by product type) Install Date: Q' Tank (2820) El Containers (2821) #of Containers: TA#: �� ) `l /Q'7 4 �- a Product Type: Total Capacity: J C � gallons (per tank or cumulative for containers by product type) Install Date:?- J �E Tank (2820) ElContainers (2821) #of Containers: TA#: 5 �� d Product Type: Total Capacity: / gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 sr� gallons Total Capacity for Site: S d gallons Comments: EHD Inspector: r' Reviewed -1 Date: By Initial: W" �.1j - 0-1By Entered Date: Initial: *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