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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: f�e�� 6� t/l��C-/. 611k/0 � 7a Page � of Facility Address: City: 7�1 tw)' I .z �' c� LIP ;-j Inspection D te: ,:i �7 - FA #: PR #: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks` and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#:17 1 Product Type: �T%i c % Total Capacity: l o.0) gallons (per tank or cumulative for containers by product type) Install Date: L:'Tan (2820) s (2821) #of Containers: TA#: F%,h l %,fib 2 al Capacity: gallons Product Type: T � � s �/ toduct (per tank or cumulative fo type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page:gallons Total Capacity for Site: gallons Comments: 17 EHD Inspector: ReviewedDate: I ( By Initial: () Entered Date: By 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 AST SURVEY FORM 09/12/08