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4 00, SAN JOAQUIN COUNTY so 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�N me: o 6 C, ' A tic Page of Facility Adcl ress� �� l w/ City: Inspecti n D eL� te150•� FA#: PR#: Progra Element: 1 2 3 D 1--K-50 Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: O-S]4 2,,5 1 Product Type: Total Capacity: gallons (per tank or cumulative or corAiners7y product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA##: 66-1 S 7 d IP 2 Product Type: r R S �/ Total Capacity: /O Ci 8 gallons _ / (per tank or cumulative for containers by product type) Install Date: ] ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: t , ( -aQ (� By Initial: —ZLR4 z *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