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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (2.09) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page r of Z Facility Add ss: city: Inspection Datp: L IN , w p� I N L --(,Ali -1— S eve- I/->� FA#: PR#: Program Element: 7 -- 6 ,52-ct 6 '� 1 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. 1:1 Tank (2820) [`Containers (2821) #of Containers: _ TA#: >�� ,2 "7 1 T Product Type: � -� e1-rM 401T--Wk 6i - (per tank or cumulative for containers by product type) Install Date: ,Tank (2820) ❑ Containers (2821) #of Containers: TA#: k6�WAq� 2Product Type: Total Capacity: 0 0 O gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 gallons Product Type: Total Capacity: CP O (per tank or cumulative for containers by product type) Install Date: P4ank (2820) El Containers (2821) #of Containers: TA#: �tSo2l9q IN 4Product Type: �]�y�C ��C�7YY1iDV�SS dl Total Capacity: C5-0 gallons (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: 9 gallons Total Capacity for bite: p i�gallons Comments: EHD Inspec eviewed Date: i Entered Date: F�;_ B y Initial: 112 By Initial: '`Aboveground storage tank means a tank that has the capacity to sto e 55 gallons or more of petroleum. —Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM n9r1 trot;