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SAN JOAQUIN COUNTY '40 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: qc f aS jn G Page of Facility Address: city: Inspection : Dat S S- r o (n1/��/ I� G lG�'t� d o T16to f FA#: PR#: PrElement: o ram 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#: 1 Total Capacity: S_gallons Product Type: �) h 1 L (per tank or cumulative For containers by product type) Install Date: ❑ Tank (2820) ,Containers (2821) #of Containers: Z TA#: 2Product Type: Total Capacity: 11 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ' ,. I3, � gallons Total Capacity for Site: �� gallons Comments: S C L P V�1 Of / G I I i t I_ _ f�@ N r6 eu� DIL S L �� 6 EHD Ins ector: Reviewed Date: Entered Date: f-,ILA—, By Initial: 1p,Z�, By Initial: 3O "A ovegro 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. EHO 28-01 AST SURVEY FORM 09/12/08