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z. `c 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: -J Gk � Page of Facility Address: City: Inspe�n te: 1/-I I 51 City: (r Alli FA#: PR#: Progrard Elemerit: 1 ( 917 1 Z3 z d 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. 13/Tank (2820) ❑ Containers (2821) #of Containers: TA#:- 1Product Type: 7 Total Capacity: -)'40 gallons (per tank or cumulative for containers by product type) Install Date: n--lank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: 2 )ro gallons Product Type: / (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (2821) - #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) 'ElContainers (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#: 8 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: f Total Capacity this Page: gallons Total Capacity for Site: gallons f Comments: EHD Inspector: Reviewed t Date: Entered Date: By Initial: 1v,'nv1 5-19-CCS 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 09112108