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SAN JOAQUIN COUNTY "*-'P-NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SJRVEY FORM Facility Name: Page -T of Facility Addreg s: city 4, -2 fl / C"X, A VE I/ Inspecti te- '7 FA X: PR 0: Program El7eot:,,� �Z- Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >1,320 gallons ji tanks* and containers". Complete one box for each tank or each cumulative container product type. D/Tank (2820) 0 Containers (2821) #of Containers: TA#, - 1 Total Capacity:gallons Product Type: .4 (pet tank or cumulative for con by'*oduct type) Install Date: U/Tank (2820) M Containers (2821) #of Containers: TA#: 2Total Product Type: Capacity: E 1-9 6 gallons (w tank or cumulative for contairws by product type) Install Date: 0 Tank {28201) ID/Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or curnutobve for containers by product type) Install Date: 0 Tank (2820) 0 Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 0 Tank (28201) 0, 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 T ictal Capacity for Site: galtons Comments: E'HD inspector iteviewed Date: By Iftal: Entered Date: By Initial *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. PHO 28-01 AST SURVEY FORM 09121108