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SAN JOAQUIN COUNTY 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: I Page of Facility Address: City: Insp ction Date: 3o I S Au Drr UZtG1-or.1 tul2�o� FA#: t2, l PR#:Ob 3O Program Element: Tank/Container Information Z 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: c3 1 Total Capacity: oob gallons Product Type: E ^ +L\* r6 1 �— (per tank or cumulative for contai ers by product type) Install Date: UN W-^ y Tank (2820) ❑ Containers (2821) #of Containers: TA#: 64 1 Q log 2 Total Capacity: �- bpp gallons Product Type: G *t. V'rO (per tank or cumulative fc contain} ers by product type) Install Date: jP1(,-,� ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (pertank orcumulalive for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ti3 gallons Total Capacity for Site: J"I S'O1) gallons Comments e l L tl f (na-�ok- h ° r0 lei EHD Inspeor: Reviewed � � ,1 Date: Entered Date: By Initial: v v� It) 1-f('' By Initial: Q O *AbovegrounU 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