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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: � � �A2 zePage of Facility Address: C''' �v � �I71 c% �� Lr f�/ /e' Inspect'on Da7o) - FA #: PR #: Program F eunent: 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. Lfank (2820) Q Containers (2821) #of Containers: TA#: �l�5j '7-3`3-3 1Total Ca acit <' t 7 Product Type: h% Z9 r�� (; 0 p y: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: f 2� Total Capacity: ; P-41gallonsProduct Type: % 1%� 4 C/ r, 0" L/ (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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: T—? gallons Total Capacity for Site: gallons Comments: EHD Inspector: Date: Entered Date: reviewed y 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