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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: /% k �X / �;�/ A/C, Page of f Facility Address: City: Inspecti�`'D e: p c • Del �r flZ- � l FA#: PR#: Program Ejqmegt- 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. 2"Tank (2820) ❑ Containers (2821) #of Containers: TqA#: 1 Total Capacity: /6" d©O gallons Product Type: ✓tt�/� _/ (per tank or cumulative for containers by product type) Install Date: 2 k (2820) El (2821) #of Containers: TA#: Tan 2 Product Type: &Z'fv Total Capacity: a�gallons —�6--n- (per tank or cumulative f co ai rs by product type) Install Date: L`T Tank (2820) ❑ Containers (2821) #of Containers: TA#: U 3 Product Type: Total Capacity: C�� 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: gallons Total Capacity for Site: / j-0 gallons Comments: ZI!,'I 171WrY EHD Inspector: Reviewed Date: �./� Entered Date: G By Initial: `/✓� -r7'� l By Initial: lg 6,�j *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