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n 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 I d T trg r' - Page 1—of Facility Address: ;City: Inspectir Date ® .✓ TK � 0 o FA#;; PR#: Progra f t: Tank/Container Information Complete for all sites with cumulative aboveground storage of;petroleum X1,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) EDContainers (2821) #of Containers: TA#: 1 Total Capacity: S/0 gallons Product Type: (per tank or cumulative for containers by product type) J Install Date: El Tank (2820) El Containers (2821) #of Containers: TA#: ! 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821) #af Containers: TA#: 3 Total Capacity: gallons Product Type: r (per tank or cumulative for containers by product type) Install Date: A � ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: 171 Tank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z/ d gallons Total Capacity for Site: Z 10 gallons Comments: 1' p EMD Inspector: Reviewed Date: / Entered Date: By Initial: �) 3,p .By Initial: LL `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 09/12108