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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: �c, W Q � — Page _L of �- A Facility Address: City: Inspecti n Date: g FA #: PR M Progr m EI ment: 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 Total Capacity: s�So O gallons Product Type: cpie�� (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: ► $ 2 Total Capacity: 25o p gallons Product Type: i esu (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: 3 Total Capacity: �0 o gallons Product Type: i csa-( (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: (> lg J cJU 4 Total Capacity: �o� gallons Product Type: ics� (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: _ c3 5 Total Capacity: moo gallons Product Type: c�i esl u (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z,po gallons Total Capacity for Site:/S oo gallons Comments: EHD Inspector Reviewed By Initial: Date: \ �.\'� Entered By Initial: Date: Pf Ltlzje- -A uno storage tanK means a tank that has the capacity to store 55 gallons or more of petroleum. **Cfiner means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/19/08