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k SAN JOAQUIN COUNTY a 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: Page of / mil L Cgs. r-ARM5 Facility Address: ` - �� City: In Peytl�� 33 �- RAIZ r !/ FA#: � �I � � � PR#: � Program Element: Tank/Container Information i Complete for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks*and containers**. Com tete one box for each tank or each cumulative container product type. /Tank (2820) ❑ Containers (2821) #of Containers: TA#: ' 1 Total Capacity: S-v a _ ___gallons Product Type: _01r / (per tank or cumulative for containers by product type) Install Date: 19- ank (2820) ❑ Containers (2821) .#of Containers: TA#: 2Product Type: .r Total Capacity: J d t� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tanis (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: I ' El Tank (2820) ❑ #of Containers: TA#:Containers (2821) - 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: " i ❑ Tank (2820) 11Containers (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: I 0 a .t°,7 gallons Total Capacity for Site: �� Q� gallons Comments: 1 EHD Inspector: Reviewed Date: Entered Date: r By Initial: +, t w1 �.�. By Initial: *fig C� I vv ' *Aboveground storage tank means a tank that has the capacity to stores gallonor more of petroleum. **Container means a storage device designed to be moved when full. ' EHD 28-01 AST SURVEY FORM 09/12108