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SAN JOAQUIN COUNTY + is s ENVIRONMENTACHEALTH DEPARTMENT H 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• L 19N �-- /ZgLf y z&- Page --/ of Facility Address: City: Inspects 7natd: Of FA#: (� PR M Prograrn Ele ent: MIT? �( C) 1 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2:1,320 gallons in tanks'and containers". Complete one box for Ieach tank or each cumulative container product tyee. ank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: Product Type: , gallons (per tank or cumulative For containers by product type) Install Date• ❑ Tank (2820) Containers (2821) #of Contain rs: A#: 2 Product Type: S Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: /f ElTank (2820) © Containers (2821) #of Containers: I TA#: 3 Product Type: I C� Total Capacity: j � gallons _ (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) s� Install Date: ❑ 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: } gallons Total Capacity for Site: �.�"S gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: :By 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. �r EHD 28-01 AST SURVEY FORM 09112/08