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SAN JOAQUIN COUNTY L.wlIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: RgL'D Shan Page / of Facility Address: p 015D Por- P-ol (22) City: Inspection Date: la'3/-13 FA #: PR M Program Element: a8� 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. Tank (2820) F-1 Containers (2821) #of Containers: TA#: 1 Product Type: IOU - Total Capacity: Moo gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: ❑ Tank (2820) .Containers (2821) 2 Product Type: }- dcilrak ��C tL Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 0 Containers (2821) #of Containers: 1 TA#: 3 Product Type: -HQQIJ� JA4S4 moi -or � i Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 0 Containers (2821) #of Containers: �— TA#: 4 Product Type: � ) 0 Total Capacity: gallons (per tank or cumulative fo ntainers 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: 3�j� gallons Total Capacity for Site: j ?jo gallons Comments: Ae EHD Inspector: �75X2 Reviewed Date: By Initial: 2(�� ( I Entered Date: By Initial: *Abt}vegrp(6d storage ti—nk-means a tank that has the capacity to store 55 gallons or more of petroleum **Co'nta'iner means a storage device designed to be moved when full. EHD 28-01 REV 04/19/12 AST SURVEY FORM