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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: h Cr'Ci-r Va if 6- f� y Page I of Facility Address: City: Inspe tion Date: c 1)0 1z r /lc FA M PR M I5c�32� Program Element: '? 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. O/ Tank (2820) ❑ Containers (2821) #of Containers: TA#: _�)C3/ 1 Total Capacity: R CC") O gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ED' Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: ��' � .; C = � - gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Ga' Tank (2820) ❑ Containers (2821) #of Containers: TA#: _(0r=, /[OO qV 3� Total Capacity: CC�C7C- gallons Product Type: 1, L/ ��z`' �/ (per tank or cumulative for containers by product type) Install Date: Ef Tank (2820) ❑ Containers (2821) #of Containers: TA#: D e /Co 0S� 4-� � . Total Capacity: C� U gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Cl' Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5Product Total Capacity: � Off) gallons Type: (per tank or cumulative for containers by product type) I nstail Date: Total Capacity this Page: gallons Total Capacity for Site: -�Z O C7 gallons Comments: G✓�.�L%��/(cC?� -X e5l la., /2 3 Z EHD Ins r: Reviewed By Initial: Date U� n 1 Entered By Initial: Date: / S.-.�__ 111 ..,�.� .,.. �wiayc .92,11, ,,,Ca„.. � a Lar, uiat nas the capacity to store 55 gallons or more of petroleum. *"Cont ner means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM