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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: �` r / Page of T_ Facility Address: City: Inspection Date - i Z 7 CrA1'J1 r c �Q� 4 // D FA #: PR M Prograin Elenient: 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#: 1 Product Type: Total Capacity: C)--9 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: 2 tT�A�1#:_� Total y: � i9 -p gallons Capacity: Product Type: Kl<S �l p (per tank or cumulative for containers by product type) Install Date: El Tank(2820) V Containers (2821) #of Containers: TA#: d 3 � TO Product Type 1j�r%� t I A.'6,- Oi L1 Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: d l qU'� 5;q ❑ Tank (2820) Containers (2821) 4 STA#: Product Type: /0411 f G� Total Capacity: Z ,rQ gallons (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: ,S gallons Comments: EHD Inspector: Reviewed� � wI Date: By Initial: 11 . �.� Entered Date: By Initial:ef O '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