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r . 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: n 'T' A 6T'/1/A►`d I) /z Page of Facility Address: City: Inspe ti n Datj: I I I C) VOAl A/ l- C Al FA#: PR M Program Element: 06 0 7 ,t? 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. ank (2820) E] Containers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: �I �� i 2 J Product Type: Total Capacity: 1� (4jl gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) E?/Containers (2821) #of Containers: _ TA#: /5b�'/ !2 a 2 9 3Total Capacity: g allons Product Type: b�^ L- C (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) L�'Containers (2821) #of Containers: ` TA#: 4Product Type: /M Total Capacity: '_� gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Containers (2821) #of Containers: TA#: J o2 5 � Product Type: j�IA Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: S /0 gallons Total Capacity for Site: 3 f p gallons Comments: JD EHD Inspector: �� Reviewed Date: Entered Date: r By Initial: By Initial: Z� *Aboveground storage tank means a tank that has the capacity to store 55 6allons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08