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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 Facilit Name: ( N L /_ Page_� of Facility Address: City: Inspect* Date: 96 vR z FA#: PR M Program Element. S-11-63 P50OJ3 oZ 1 z., a 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. 9,'fank (2820) EJContainers (2821) #of Containers: TA# 1 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#- 8 Le 42 2 Product Type: 02 Total Capacity: ' a2 gallons (per tank or cumulative for containers by product type) Install Date: ❑ LEYC Tank (2820) ontainers (2821) #of Containers: TA#: Z�aXD 7 3 Total Capacity: / �0- gallons Product Type: A:''C7;rW . Of, 0 (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: /f)6-1 g 7 Liz 4 � Product Type: Total Capacity: � � gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) 11Containers (2821) #of Containers: TA#: 5 Total Capacity: b�11 gallons Product Type: 3 (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: �_) 0 gallons Total Capacity for Site: ('' gallons Comments: e- YA 0a N EHD Inspector: Reviewed Date: Entered ,^ Date: p <' By Initial: VA By Initial: ,1//K/ *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