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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: 6 r/<r� ✓L A/� G Page ^L of I Facility Address: City: Inspection Date: l iAl- L06il,11 77PL-FF At 1- FA#: PR M Program Element: 1 0507- $ 'L 9'�;v 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. �ank (2820) ❑ Containers (2821) #of Containers: TA#: g0 / p 1 Product Type: r�/ Total Capacity: gallons (per tank or cumulative for c ntainers by product type) Install Date: W/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 r Product Type: 42, Total Capacity: J o 0 gallons —� (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: 2' gallons Product Type: (per tank or cumulative for containers by product type) Install Date: [I Tank (2820) L�Containers (2821) #of Containers: _ TA#: � f`t�D/ 4 !- Product Type: Total Capacity: gallons (per tank or cumulative for containev<by product type) Install Date: ElTank (2820) elcontainers (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 "q gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: *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. EHD 28-01 AST SURVEY FORM 09/12/08