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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: 7 �� T /J�� /�r� ��/16 �A y✓� Page of Facility A—d7dress: City: /'_ l Inspecti n D te: FA#: �� PR#: g Program E m�uf: �� J 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. L7 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: � t,? gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: 919,;), 2 Total Capacity: 10170gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Z Containers (2821) #of Containers: TA#: 5?f R2 3 Total Capacity: �, �� c� gallons Product Type: ��//� S T 0 f �/ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) PfContainers (2821) #of Containers: TA#: Q 1 RDD 4 Total Capacity: df- gallons Product Type: per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) P Containers (2821) #of Containers: TA#: z9 5 Product Type: /t7�"TOZ," 4' Total Capacity: � ---�� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 gallons Total Capacity for Site: y gallons Comments: EHD Inspector: Reviewed Date: EnteredDate: By Initial: rLj_0� By Initial: hl "'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