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SAN JOAQUIN COUNTY =` tNVIRONMENTAL 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 STORAGE1PROGRAM SURVEY FORM ' Facility Name, j�4E C A�n L t3 g vr)� Page of. Facility Address: Icity: Inspectio ateWal• FA#: PR C. Pro le n :h 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#: 1 Product Type:--- - . Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) #of Containers: TAM , f 2 Total Capacity: gallons Product Type:- (per tank or cumulative for containers by product type) Install Date: E ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821) #af Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Instal! Date: ❑ Tank (2$20) El Containers (2821) #of Containers: TA#: +I 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total.Capacity this Page: gallons TTotal Capacity for Site: gallons Comments: i f i EHD Inspector: _7Reviewed Date: Entered Date: ! By Initial: � C�'�� By Initial: /2 1, /'P'?" *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