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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: I,� U- Sr &c�Y^ (. Yv ul ft - Uet.Tff-L- m4ilv�- Page 2-ff Facility Address: c /Ja ( [(1�� E 4l'GL 44r 19�`� 66. - City: � G qnspeo on ()--7 FA#: v ( PR B r 2O _ rogZ J�lam Tank/Container Information lS 3 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#: _ B5/ $Rc33 1 Total Capacity: ( U gallons Product Type: p r4v j 0j'(_ (per tank or cumulative for containers by product type) Install Date: 20 5 I Tank (2820) ❑ Containers (2821) #of Containers: , ff TA#: if 6�� $q3y 2 Product Type: (rl� r�"U 1I6 Q/ C Total Capacity: 0 gallons (per tank or cumulative for containers by product type) Install Date: 2 OU Tank (2820) ❑ Containers (2821) #of Containers: ! / TA#: �h JSq 3tY �/ �`�2I i G O�C Total Capacity: l 3 � gallons Product Type: A) (per tank or cumulative for containers by product type) Install Date: 2�" 1 ❑ Tank (2820) Containers (2821) #of Containers: 3 TA#: 19�Z�1�(n 4 Total Capacity: io S gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: 2 TA#: 5 Total Capacity: ( D gallons Product Type: (per tank or cumulativeforcontainers by product type) Install Date: Total Capacity this Page: V gallons Total Capacity for Site: O gallons Comments: EHD Inspector Reviewed Date: Entered Data: By Initial: By Initial: of v *Aboveground sthrage 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 09/12/08 AST SURVEY FORM