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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: C Page / of � Facility Addre city, Inspe ion Date: �0-7 S �a� fl-ru��r -Tri /5//C) FA#: PR#: Program Element: I -7� 0 5 / �/ C5 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. IR/Tank (2820)T ❑ Containers (2821) #of Containers: TA#: p S 1 (.r o U0 1 Total Ca acit �0, 000 Product Type: �isd p y: gallons (per tank or cumulative for containers by product type) Install Date: ®/Tank (2820) ❑ Containers (2821) #of Containers: TA#: _ Q S I 2 Product Type: Total Capacity: 25b gallons (per tank or cumulative for containers by product type) Install Date: Y/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3Product Type: Total Capacity: '�"5 C) gallons — - (per tank or cumulative for containers by product type) Install Date: Lt!' Tank (2820) ❑ Containers (2821) #of Containers: TA#: / 4 -7--) Product Type: Total Capacity: —1gallons (per tank or cumulative for containers by product type) Install Date: VTank (2820) ❑ Containers (2821) #of Containers: ,T,rA#: 5 gallons Product Type: Used/ 0/� Total Capacity: /p (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2� ►U gallons Total Capacity for Site: gallons Comments: le-WOv4!f Ilg EHD pecto . Reviewed Date: Entered Date: By Initial: -1.NO.VO By Initial: " ov ound storage tan means a tank that has the capacity to store 55 gallons or more of petroleum. **C6ntainer means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08