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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 fPROGRAM SURVEY FORM " Facility Na L 1/us- 13 Roy Page —Z— of Facility Address: City: Inspects t . v L r a / o FA#: PR#: Program Element: l6 2 e o - Z $ o Tank/Container In ormation Complete for all sites with cumulative aboveground storage of petroleum 2-1,320 gallons in tanks*and containers". Complete one box for each tank or each cumulative container product type. ❑ nk (2820) ❑ Containers (282 1) #of Containers- TA#: 1 Product Type: /-� 2. Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: O ank (2820) ❑ Containers (2821) #of Containers: Tft#: 2 r Product Type: Total Capacity: `LJ � gallons (per tank or cumulative for oontainers by product type) Install Date: 0 Tank (2820) ontainers (2821) #of Containers:, TA#: 3 Total Capacity: gallons Product Type: /n,,+, (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: �V (per tank or cumulative for containers by product type) Install Date. Total Capacity this Page: gallons Total'Capacity for Site: gallons Comments: A.5 2b a? EWD Inspector Reviewed Date: 1 Entered Date: � By Initial: l`�� By Initial: *Aboveground storage tank means a tank that has the capacity'to store 55 gallons or more f p troleum. "*Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09112108