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i ry s SAN JOAQUIN COUNTY 4 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: H C o d "7" A �^'� S Page °f—� Facility Addzress: CAY: Inspectn Da7Dq a 5' Vr1,� LL-� FA#: Pit# Progra en: 0�� L 9 7 -9 .V 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) ❑ Containers (2821) #of Containers: TA#.- 1 Capacity: elf gallons Product Type: z 1,� %1 Total Ca acit -• (per tank or cumulative for coniFtners by product type) Install Date: L� Tank (2820) ❑ Containers (2821) #of Containers: T�\#: 2r Product Type: Total Capacity: 3 �{ gallons _ - ---- (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: /T 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: r ❑ 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 Total Capacity:' 1-1 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: C C:? gallons Total Capacity for Site: J Z gallons Comments: EHD inspector: Reviewed Date: Entered Date's By initial: 9ILo-� By Initial: �]�� *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 09/12/08