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SAN JOAQUIN COUNTY y 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: _ cTa f�i; AIQ�'1 S Page L of Facility Addre s: 14/- , / City: Inspectiop Date: 1 lel - � 6—)C- & ill 3 /o9 FA#: PR M Program Element: / d ©�a q /N- I -L '3 V Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product tyee. /Tank (2820) ❑ Containers (2821) #of Containers: TA#: /95:,17 R 1 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: V. ank (2820) El Containers (2821) #of Containers: TA#: � ✓" /77� Total Capacity: / 0 el y gallons Product Type: /' r (per tank or cumulative for containers by product type) Install Date: Cl D tz I—U7 V r q"S U50) ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: �' Z G7 L� gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: l ✓ By Initial: By Initial: *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