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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: / 0 /✓ r� /JAS Page J_of Facility Address: City: Inspe do Date;, 6��c/I - /1�y FA#: PR#: Program Elen7 t: 5'� 053 2S " Q 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. L�'Tank (2820) ❑ Containers (2821) #of Containers: TA#; 6 5/�o73D 1 Product Type: ,��„/�-�K Z�� Total Capacity: 0 0 G/ gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: > TA#: 3 2 ,r0 � Product Type: Total Capacity: J gallons (per tank or cumulative for containers by product type) Install Date: 01 ank (2820) El Containers (2821) #of Containers: TA#: I 2o � 3 Product Type: T'C Total Capacity: gallons (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 fo 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: / 93 j A gallons Total Capacity for Site: 3S gallons Comments: d in/ TA. ' 'Zo : vi �o II EHD Inspector: V Reviewed , - +` Date: Entered Date: C' By Initial: wo By Initial: l4,9 *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