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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 Nam 0Page _� of Facility Address:p i -LfN1=5� / City: or✓ 120b Inspec on Da : g Z ( $ FA MPR 7 : _a o Prog am Element: 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 type. Tank (2820) ❑ Containers (2821) #of Containers: STA##%:) 1 Total Capacity: �� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: DI Tank (2820) ❑ Containers (2821) #of Containers: ITA #: 2 Total Capacity: //t> gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#:: 3 I (— Total Capacity: > t�i�i gallons Product Type: (per tank or cumulative for containers by product type) Install Date: In- Tank (2820) El Containers (2821) #of Containers: TA#: 1 Q l D a 4 Total Capacity: r gallons Product Type: - (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 16 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z / 0 gallons Total Capacity for Site: 2 gallons Comments: Grp VA I& `Z o EHD Inspect�� Reviewed Date: By Initial: $,%� -� Entered Date: 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