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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 PROGRAM SURVEY FORM Facility Name: 7L / PO � p-/ /w Page of Facility Address: City: Inspection Date: /S 2/ 1,-0 - . 02 9 // FA#: PR#: Program lement: 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. ED Tank (2820) ElContainers (2821) #of Containers: TA#: g, 2 421-42 1 Total Capacity: / D gallons Product Type: 0/'/ /0 (per tank or cumulative for containers by product type) Install Date: El Tank (2820) i/Containers (2821) #of Containers: TA#: 1Q� a��'7 2 Total Capacity: 2 -7e gallons Product Type: ke.-K�SCIO"?� (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Q Containers (2821) #of Containers: TA#: _- aa � 2 3 Product Type: C,I s e d 0/ Total Capacity: (-,9 � � gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) E�Containers (2821) #of Containers: TA#: QSaQaa / 4 Total Capacity: Product Type: / &� 66� L 7 �Q i2 p y: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: GI gallons Total Capacity for Site: 0C_115gallons Comments: �2Zs - O 0 al , S EHD Insp r: Reviewed Date: LEntered Date: By Initial: K �1 ial: y 1 *Abov Fou torage tank means a tank that has the capacity to store 55 gallons or more of petroleum. AG I **Con r means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM