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SAN JOAQUtN COUNTY ENVIRONMENTAL:HEALTH DEPARTMENT ' R 600 East Main Street;jStockton, CA 95202-3029 Telephone: (209)468-3420 Fax:{209)468-3433 Web:www.sj9ov.orglehd I, ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page of tj Facility Address: ,I City: Inspectlo Date - Y 0 FA#: PR#: Progra le n - / '7/ `7 P5.3 D TanklContallner Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks* and containers". Complete one box for each tank orleach cumulative container product type. _ C2-lTank (2820) ElContainers (2821) #of Containers: TA#: 1 Product Type: 4 JC Total Capacity: gallons 0 (per tank or cumulative for c6tafters by product type) Install Date: ank (2820) ❑ Containers (2821) #o,'f Containers: TA#: _i 4 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) I nstal I Date: #of Containers: �_ TA#: .4 EDTank (2820) Containers {2821} �, 3Product Type: !� Total Capacity: s gallons i (per tank or cumulative for containers by product type) Install Date: i; ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type. _ Total Capacity: gallons i -- (per tank or cumulative for containers by product type) ` Install Date: i; ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: .I 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) ' Install Date: Total Capacity this Page: _5_j gallons Total Capacity for Site: TfT gallons Comments: Z 0 9J, -3 1-2 4.4112 pG EHD Inspector: Reviewedtj. Date: Entered Date: 8y Initial: i i 8y 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 l� AST SURVEY FORM 09/12/08 i