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SAN JOAQUIN COUNTY *` ' ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Pax:(209)468-3433 Web:www.sjgov.org/ehd ,- ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name:/� /- - Xt 7&ae14?�r '• �'�G��G/ Page l of 1 Facility Address: City: Inspec on ate: i 470 T., 77-a 60 e/Vd- 76_1-f r FA#: PR M Program Element: 9�9Z o�25.02 aI Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum k1,320 gallons in tanks*and containers**. � Complete one box for each tank or each cumulative container product type, CR/Tank (2820) ❑ Containers (2821) #of Containers: TA#: Q5/9u�/ 77 1Product T S Total Capacity: _ OO _gallons Type:. �0 (per tank or cumulative for containers by product type) Install Date: C3Tank (2820) Li3'Containers (2821) #of Containers: i TA#: 5 2 Product Type: eyz&C 017, Total Capacity: i� gallons �. (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) LSE Containers (2821) #of Containers: _� TA#: _ �/�f 6�Q { 3 Total Capacity: f5�0t5 gallons Product Type: (per tank or cumulative for containers by product type) Install-Date: 4 ❑ Tank (2820) LAS Containers (2821) " #of Containers: �_ TA#: �L1 5�24-1 4 I Total Capacity: 2 O I) gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Container's: d'L ❑ Tank (2820) Containers (2821) iTA#:-�- 5 Product Type: Total Capacity: / � gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Q 2 gallon's Total Capacity for Site: 4D75 gallons Comments: f465 o7ia 520 O a OF , O Ze t ' i EHp In ctor: Reviewed Date: Entered Date t By Initial: +p•�0 g 4 Y Initial: r v *Ab egr nd storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **C ner means a storage device designed to be moved when full. EHE 2B-01 09/17108 AST SURVEY FORM