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s 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: '; L Page of Facility Address: 9 S ity: -Z'-Z-7 6 - bt-IAMS ra InspectioDate: 3� � FA #: /'73 PR #: Progra EIement:yl 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: fj o2 1 Total Capacity: S O/% gallons Product Type: /, S d (per tank or cumulative for containers by product type) Install Date: 2-/Tank(2820) ElContainers (2821) #of Containers: TA#: 2Product Total Capacity: �0�� gallons Type: (per tank or cumulative for containers by product type) Install Date: D - -Tank (2820) ❑Containers (2821) #of Containers: TA#: 3 � Total Capacity: 3 0 ) gallons Product Type: (per tank or cumulative for containers by product type) Install Date: M -Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: � L� gallons Product Type: X12, (per tank or cumulative for containers by product type) Install Date: 0 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: //'134k I/ Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z vC > e5jgallons Total Capacity for Site: Z C� © gallons Comments: EHD Inspector: C Reviewed Date: By Initial: \ Entered Date: I By Initial: j�-- '`Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleurh. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08