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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: S kt,V r? `l Page�_ of / Facility Address: City: Inspection Date: �s-70S Aej-V' P 2� 7Tr� LAI FA#: 6 2�- /v PR#: Program Element: EA b D 1 l 61 S D53 (t�> OS 293 2 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. R"Tank (2820) ❑ Containers (2821) #of Containers: j TA#: a-'5-I q 780 1 Product Type: Total Capacity: 12 6 D o a gallons (per tank or cumulative for containers by product type) Install Date: LJ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2Product Type: � Total Capacity: 1 ZG 0b o gallons (per tank or cumulative for containers by product 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: /1 Reviewed / Date: Entered Date: By Initial: 1`� 6/"L / 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 09/12/08 AST SURVEY FORM