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4 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: iF Al �/l1 S /✓ Page f of Facility Address: City: Inspection Date: / 592- -Z- '�?4y �4J z FA#: PR#: Program Element: �3D 2 '30 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 49 gD R 1 1 Product Type: 17.c Q Total Capacity: ��_gallons (per tank or cumulative for containers by product type) Install Date: 9-Tank (2820) ❑ Containers (2821) #of Containers: TA#: Q4-Tj 90Ra 2 r Product Type: Total Capacity: � �� gallons (per tank or cumulative for containers by product type) Install Date: Lg-Tank (2820) ❑ Containers (2821) #of Containers: TA#: D 3 Product Type: z7'�� Total Capacity: -3 � gallons (per tank or cumulative for containers by product type) Install Date: Ly'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: '3 � gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 2-c"Ontainers (2821) #of Containers: TA#: 5Product Type: h�,�y►a! J �l Total Capacity: S� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 16 gallons Total Capacity for Site: 0 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: 0 By Initial: By Initial: A *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