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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: f ' f AM GI'tAP0 �)A/ Page of J---. Facility Address: City: Inspect'on Da S ��c luJ f�A rc q 0 FA M PR#: Program E ement: 330!2,9 -7 g - n 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. EY/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 96-1 1 Product Type: �� Total Capacity: / 0 Q gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: L'� Tank (2820) ❑ Containers (2821) g Aq 2 Product Type: >'A,� Total Capacity: l v r� gallons (per tank or cumulative for containers by product type) Install Date: TZank (2820) ❑ Containers (2821) #of Containers: TA#: /9`k .j 3 20 � Product Type: Total Capacity: 19 gallons (per tank or cumulative for containers by product type) Install Date: �/ #of Containers: TA#: ank (2820) Ly"Containers (2821) � 4Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: Tank (2820) Containers (2821) — o 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: 15� 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 bf petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08