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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: C A r QN f t h qn /) PagEElement:ta Facility Addres r City: Insp FA#: PR M Progra 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) XContainers (2821) #of Containers: TA#: e9,,9j 1 Product Type: Un (-LCL) 11 L 6>1 Total Capacity:gallons 76A� (per tank orcumulative for containers by product type) Install 6g /raAl` ❑ Tank (2820) ,('Containers (2821) #of Containers: TA#: /q ,S 2 Total Y Ca acit T � gallons Product Type:pe: �/�q�s Pt u h P P (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 716gallons Total Capacity for Site: TTF gallons Comments: EH spector: Reviewed Date: Entered Date: n By Initial: By Initial: "Above round storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. �L `*Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08/08