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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: Page of �-- Facility Address: 4 City: Inspec fon Date: 2caDO FA M PR#: oO� � Program ement: �J O 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. a Tank (2820) ❑ Containers (2821) #of Containers: TA*:: 1 Product Type: �il',�e�,/,/ O / Total Capacity: 5�� gallons (per tank or cumulative for containers by product type) Install Date: 15 Tank (2820) ❑ Containers (2821) #of Containers: TA#: _(7 2Product Type: Total Capacity: '4 0 0 0 gallons (per tank or cumulative for containers by product type) Install Date: IR Tank (2820) ❑ Containers (2821) #of Containers: TA#: S-2/-7 3 Product Type: �&e G� O/ Total Capacity: 2 �O gallons (per tank or cumulative for containers by product type) Install Date: 19 Tank (2820) ❑ Containers (2821) #of Containers: TA#: _/� c:�/ -7 0 2 cl;�' 4 Product Type: G ll&P O Total Capacity: 2 6(� gallons / (per tank or cumulative for containers by product type) Install Date: 6V 7w- ❑ Tank (2820) EJ Containers (2821) #of Containers: 2/ TA#: 0 5/ 7 �L \ 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: J5 !� gallons Total Capacity for Site: O -f— gallons Comments: / � ru hl . 41)!� --3;3b �5s 331015173�✓ 7 5" / EHD We Reviewed Date: Entered Date: By Initial: �J r Y� By Initial: a�.q / "Ab e and storage tank means a tank that has the capacity to store 55 gallons or more ol petroleum. "Co ainer means a storage device designed to be moved when full. EHD 28-01 08/12/08 AST SURVEY FORM