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w 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 PROGRAWSURVEY FORM Facility Name: 01 �+�. 1C,—r E'7-Q?: a e f of 7 o - I iIt1V TO CIA J ' I 9 1 Facility Address: or City: Inspection Da 2— 7- 7 C? S tlAll ,A/ r1,7 AJ T F-C,,4 /(7/1 r " FA M PR#: Program EI ent: 9? 17 D 03 zg �D Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative containerproduct type. Tank (2820) ❑ Containers (2821) #of Containers: ToA#: 1 —gallons Product Type: Total Capacity: (� -- (per tank or cumulative for containers by product type) Install Date: /Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: jJ gallons Product Type: S (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) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Data: ❑ 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: V17 gallons Total Capacity for Site: /0 19 P gallons Comments: GI3Zfl EHD Inspector: J Reviewed Date: Entered� Date:. By Initial: �, . �� By Initial: 9 *Aboveground s orage 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 09/12108 4, - �'�