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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: T/ �Il�ef�l �O�Sf Page of Facility Address. City: � :ln:sZcon te: FA#: PR M Program lament: "2e.3/ 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 "E7�(Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: 000 gallons Product Type: �s�.,�� (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: �- TA#: �� 2 Product Type: Q//lam 61al Total Capacity: gallons (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 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: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Q gallons Total Capacity for Site: gallons Comments: EHD In ctor Reviewed Date: Entered Date: By Initial: By By Initial: J /5_/ "Ar-v—qgr6und storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Cbritainer means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08