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y.. 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: C H TO r� Page _of Facility Address: City: Inspection Date: /� z 9 4w r- �q d FA M: PR#: Progirarin ent: 05a� 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. D-- ank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: '� 0 C) gallons Product Type: 42% 2 (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: 0-09 gallons Total Capacity for Site: Z gallons Comments: EHD Inspector: „✓ ReviewedDate: l' Entered Date: ` ` By Initial: tj "1-'Lj9-� By Initial: 'q/t O "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