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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR'TMENT 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: p e - Z,D L% � 7, / Page � of Facility Address: Ci �. i' � �J Z � Inspect n D te: FA#. PR#: Program E eme t: N67cq t7 900 �40 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers`*. Com fete one box for each tank or each cumulative container product type. Ey Tank (2820) ElContainers (2821) #of Containers: TA#p, 1Total Capacity: D gallons Product Type: /rx (per tank or cumulative for con ainers by product type) Install ©ate: Tank (2820) El Containers (2821) #of Containers:1. TOA4 - �� 2 Total Capacity: #- > gallons Product Type: (per tank or cumulative for rontainers by product type) r Install Date'. ❑ Tank (2820) El Containers (2821) #of.Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: i ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: � Ii 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: i ❑ 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 I Total Capacity for Site: gallons Comments: AL G EHD Inspector: Reviewed Date: Entered Date: By Initial: VA i5.k°l-0� By lnitial: *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 09/12108