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SAN JOAQUIN COUNTY y 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: ;';'70 ! r S Page l of Facility Address: City: Inspection Date: ZSR S. - ) 5587 '-- 'zI a � FA#: PR#: Program Element: 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 eroduct type. E�'T'ank (2820) ❑ Containers (2821) #of Containers: TA#: r 1 Total Capacity: ,?r',,-7 gallons Product Type: _ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containersby product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: Product Type: p y: 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: gallons Total Capacity for Site: 3 gallons Comments: EHD Inspector: .- Reviewed Date: Entered Date: By Initial: 1(� By Initial: A �B "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. EHp 28.01 AST SURVEY FORM 09/12/08