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SAN JOAQUIN COUNTY '4-- . -v NVIRONMENTAL 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: C j-;'7 S Page T of Facility Address: City: Inspect* n D te: / O FA JPR#: Prog"ram Elemow 93 �C? TanldContainer 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. Tank (2820) ElContainers (2821) #of Containers: TA#: 1 Total Capacity: C)(9 gallons Product Type: a (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: i ` #of Containers: TA#: ❑ Tank (2820) ❑ Containers (2821) 3 Product Type:. Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 11Containers (2821) #of Containers: TA#: 8 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: gallons Comments: 20 g �� - a ar- EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: p '"Aboveground storage faink means a tank that has the capacity to store 55 g lions or more of petroleum. "*Container means a storage device designed to be moved when full. EHD 28-01 , AST St1RVEY FORM 09/12/08