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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: �/ +61A elf L Page of Facility Address: City: Inspec on Date• FA#: PR M Progr m E e ht bZ '70222 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: / 1Product Type: i e sem, ifo e L Total Capacity: S0y gallons (per tank or cumulative for containers by product type) Install Date: N Tank (2820) ❑ Containers (2821) #of Containers: TA#: /26-12706' 2Product Type: i e,��. U�L- Total Capacity: �Ut� gallons (per tank or cumulative for containers by product type) Install Date: 1 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: (Z!e )y I4.l C)N j eAh4 6j�j()1 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: 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: I sbo gallons Total Capacity for Site: gallons Comments: EHD I ctor: Reviewed Date: Entered Date: By Initial: By Initial: r LA q *Abovegro nd 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