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y I) SAN JOAQUIN COUNTY M 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: 50rJ A /4 Page of Facility Address: I City.. Inspect S'O'/ 0 FA #: 65 PR M Program Elerrkn� 'L� s e6 o�n� 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#: eEt$ Z .3 42 1 Total Capacity: gallons Product Type: / (per tank or cumulative forWYIWners by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 6-127 72 7' 2 Total Capacity: � gallons Product Type: CAS D (per tank or cumulative for containers by product type) Install Date: El Tank(2820) Containers (2821) #of Containers: 3 Total Capacity: //0 gallons Product Type: / ,5 (%1 Ll (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: C) gallons Total Capacity for Site: 0 gallons Comments: EHD Inspector: Reviewed Date: By Initial:'l , �0 . Entered By Initial Date: 9' *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