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40 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 Na � C N C-1Page of I Facility Address: City: Inspection e: Sa lL,�dr✓ ( -Da a FA#: PR#: Program Element: / 72- / 7 5D -7 - a Tank/Container Information Complet 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: TAc#: 1 Product Type: U'A Total Capacity: 00 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for ntainers by product type) Install Date: J*ank (2820) ED Containers (2821) #of Containers: TA#: ,0j'D '6(n"$'S1" 3 Product Type: 41/�T �- n> Total Capacity: % C� gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) E Containers (2821) #of Containers: TA#: 4 Product Type: ; d Total Capacity: J � gallons (per tank or cumulative for containers 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: Z gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleunk "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08