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N ' 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: d i, N04 s0 N 1140 Page --L of �— Facility Address: City: Inspectio Date: ale 15- Lov/S /�� " � A FA#: PR#: Progra Element: `7 1 2 3�p 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. Cjank (2820) El Containers (2821) #of Containers: TA#: 4 1 Total Capacity: 2..o-" gallons Product Type: gA s d e2 (per tank or cumulative for containers by product type) Install Date: U Tank (2820) ❑ Containers (2821) #of Containers: TA#: �,��975 2 2—cProduct Type: T)L Total Capacity: � �� gallons ti (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: ��')�s'726 3 Product Type: Total Capacity: " gallons (per tank or cumulative for containers by product type) Install Date: le"Tank (2820) ❑ Containers (2821) #of Containers: TA#: $a%`7 4 Product Type: 05.4 > O/ Total Capacity: gallons (per tank or cumulative for co ainers 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 Comments: EHD Inspector: Reviewed Date: Entered Date: C� By Initial: v4.0 By Initial: —Z z!�-z-:r "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