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SAN JOAQUIN COUNTY r 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: , L- A C� 7 o � 3 $ / Page of Facility Address: � City: Inspectlanpateii' 7/// 0 FA#: PR#: Program Element:n 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. i` Tank (2820) ❑ #of Containers: TA#:Containers (2821) r-� o 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: .ff Tank (2820) ElContainers (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' Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: !❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Tota! Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: U gallons Total Capacity for Site: 0 gallons Comments: a I EHD inspector: Reviewed Date: Entered Date: By initial: V-44 "�•�.O By Initial: /2 10 *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 09112/08