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`'• •'+� rti SAN JOAQUIN COUNTY F YNVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd 1' ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY;FORM Facility Name: Page -L.-- of 4 = 0 145 T 0 _ Facility Address: p Inspectl Dat o 2»3 q S• o (,/ i' A U �� o FA#: PR#: J Pr69famlietbentit I P6,19& Z Tank/Container Information Complet for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers". I Com lete one box for each tank or each cumulative container product ty2e. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type:;- Total Capacity: gallons 1 —"T (per tank or cumulative for c6ntainers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of;Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) I nstal I Date: ❑ Tank (2820) ElContainers (2821) #o#Containers: TA#: 3 Total Capacity: gallons Product Type: } (per tank or cumulative for containers by product type) Install Date: r ❑ 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: ❑ Tank (2820) ❑ Containers (2821). #ofi Containers: TA#: 5 Total Capacity: gallons Product Type: R Y (per tank or cumulative for containers by product type) Inst al I Date: I. Total Capacity this Page: S501 gallonsj Total Capacity for Site: �� gallons Comments: Rn p / yam;: 7 d — 1 aq EHD Inspector: Reviewed Date: Entered Date: f� By Initial: `l (fj' By Initial: D "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 09112Ios