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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 2 of Facility Address: City: Inspection Date: 2�O O �a r FA Program Element: 29-'-32 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. ED/Tank (2820) ❑ Containers (2821) #of Containers: TA#: OS/CoC�5/w 1 Total Capacity: 2 DOD gallons Product Type: L7 6aS0 61/-2 (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: Lr Tank (2820) ❑ Containers (2821) /(�Q 2 Product Type: -1-2:>/ e�S Total Capacity: 2 �C� O gallons (per tank or cumulative for containers by product type) Install Date: Ell Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: Product Type: �/ 2�� gallons yp uS>°� (per tank or cumulative for containers by product type) Install Date: J ❑ Tank (2820) EV Containers (2821) #of Containers: .� TA#: 4 . Product Type: Z)/ P SC1 �'e-lq-ef/--a �DI3 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 19'Containers (2821) #of Containers: TA#: Dot 5 Total Capacity: r 0 0 0 gallons Product Type: o D e;r -/-D�f�l (per tank or cumulative for containers by product type) Install Date: Cc�a,;--t t Total Capacity this Page: ,r5- —o gallons Total Capacity for Site: 5 gallons Comments: Cr-G/ EHD Ins ector: — Reviewed Date: Entered Date: By Initial: u l�i fiU `� By Initial: J, * oveg and storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. ** iner means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM,