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..' SAN JOAQUIN COUNTY 1.00 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: Q LN Q RAAIC, 14 Page of Facility Address: / ./' b � � ^ N L�� r City: In.Pectl 2 Dat.: FA#: �� PR k: Progrenam I 173s o a s z7' /- 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: TAM 1 Total Capacity: 3 )�O gallons Product Type: _ (per tank orcumulative for containers byproduct type) Install Date: L"r Tank (2820) ❑ Containers (2821) f Containers: TA#: 2 — 0 Product Type: ✓/9.S Total Capacity: 2i gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 7 f! o gallons Total Capacity for Site: 7 Q o gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: � 5-(C1,pcN I By Initial: *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