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SAN JOAQUIN COUNTY "1111ENVIRONIVIENTAL 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,:4 r r r _ :S r- - Page of acniWAddress: City: Inspec onppat : fl oo '7 oma . � /a FA#: r-' PR#: Program Elemextt: J v�r� rVJ Tank/Container Information Complete for all sites with',cumulative aboveground storage of petroleum 2,1,320 gallons in tanks* and containers". Cam fete one box for each tank or each cumulative container product type. Q/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: 56 d gallons Product Type: �� (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: �. TA#: r 2 Product Type: "� d 1 CJ Total Capacity: �� gallons ' - (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) ❑ 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: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: J_S J gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: ��}-t�� 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