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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: fir— 1 5 )� /L / f Ap (JS Page Z— of C Facility Address: Cit Iq Inspec i n D 77� S'lZ FA #: PR #: Progr m Element: Jo Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2_1,320 gallons in tanks` and containers". Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) gContainers (2821) #of Containers: TA#: d 1 �-� Product Type: CV Total Capacity: ; �, gallons (per tank or cumulative for containers by product type) Install Date: El Tank(2820) 19'Containers (2821) #of Containers: TA#:/�� 0 2 1 Product Type: %'f �' % (?/Z all - Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: gallons TTotal Capacity for Site: gallons Comments: EHD Inspector: , Reviewed Date: Entered Date: — 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 ripm?/m