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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: Page of f Al B r''r Facility Addres City: InspectioDat 3r 95` pS1 - C' Ir tec FA#: PR#: 1Program Element: 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. #of Containers: TA#: 14/Tank (2820)T ❑ Containers (2821) / �l—r 1 Product Type: 1, 6 Total Capacity: C90 gallons —� (per tank or cumulative for containers by product type) Install Date: C/Tank (2820) El Containers (2821) #of Containers: TA#: 0,-JJ J62 2 Total Capacity: rgallons Product Type: (per tank or cumulative for corlfain6rs by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 gallons Product Type: Total Capacity: � � g (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: * T 4 Product Type: Total Capacity: 5&6 gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Ef Containers (2821) #of Containers: _ TA#: J 5 Total Capacity: 41� gallons Product Type: i4iA S (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: -2, T�� gallons Total Capacity for Site: gallons Comments: J S r� EHD Inspector: c Reviewed Date: Entered Date: C'( By Initial: ��-�0-�� By Initial: Z4Z4rLOL *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more ol petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08