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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: _ �IFJ %7 / /V k % lel:-= '!:� �� '��'j'S �c Page 2--of Facility Address: City Inspect' n D te, cq FA#: PR M ProgramF &15C2 �Ai 'Tg '2 a nt Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers`*. E?- Tank (2820) Complete one box for each tank or each cumulative container product type. LdTank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: /!i'G) (per tank or cumulative for containers by product type) Install Date: ® Tank (2820) Ly'Containers (2821) #of Containers: ? TA#: 0 $p33 2 -�-7 Product Type: �7 f Total Capacity: /' gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 56"C"Ontainers (2821) #of Containers: . TA#: 3 Product Type: , /i'�/ 1 g/^ Total Capacity: f� gallons (per tank or cumulative for containers by product type) Install Date: Ly'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: /f o o gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: &9`: 2 5 •-- Total Capacity: h ol; gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z 3 gallons Total Capacity for Site: gallons Comments: EHD Inspector: _ Reviewed Date: Entered Date: f 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