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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 lehd Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sjg0v.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r ' page i of � .�( W— 0 dt City: In coon pate: Facility Address:43 T3 6, � 6 I b 2OI 0 c PR M Program Element: FA M li�A PP, 0,5ZQ 2Z 2S �- Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum;1,320 gallons in tanks""and containers". Com fete one box for each tank or each cumulative container product type. #of Containers: �___ TA#: r 2 Tank (2820) ❑ Containers (2821) I Product Type: apacity: 2& gallons L/A !,M a&^1 ./, (per tank or cumulative for containers byproduct type) Install Date: t� #of Containers: ._._ TA#. Tank (2820) ❑ Containers (2821) 2 Total Capacity: l gallons Product Type: Dr'1 ZC '� ff 7 {per tank or cumulative for�ontainers by product type) Install Date: w 2820 _Containers 2821) #af Containers: � TA#: ❑ Tank ( ) s O r 11 3 3 � YO_gallons Product Type: � ` � �� x I Total Capacity: (pet tank or cumulativPLO vi e for containers by product type} Install Date: ❑ Tank (2820) ❑ Containers (2$21} #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#: 5Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: n gallons Total Capacity for Site: ] 2 c7,9Q gallons Total capacity this Page: Z 9a Comments: ./ r r` Awe S kl S I D D© rsn i re-I�nQ r d of OVAL "� EHD Inspector: Reviewed _ _1 ]ate. Entered Date: �g(� By Initial: �V�" b.��.(t7 By Initial: L�"Aboveground storage tank meansA tank that has the ca acity to store 55 gallons or more of petroleum. —container means a storage device designed to be moved when full. AST SURVEY FORK EHD 28-01