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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: /� 08, L % L uC jvf V N � �1 �-l� S Page - of Facility Address: City: -z' � v Inspe n Dat �15Tb FA #: / PR M Program 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. Tank (2820) ElContainers (2821) #of Containers: TA#: 1Product o � TotAl Capacity: ' to D 0 gallons Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) Containers (2821) #of Containers: `'� TA#:1� -1 2 Product Type: ,�y/),2pL�l ci 0/ iJ Total Capacity: gallons (per tank or cumulative for cont iners by product type) Install Date: El Tank(2820) i�Gontainers (2821) #of Containers: TA#: 3 Product Type: /y%4 T(IZ' IQ f C� Total Capacity: gallons (per tank or cumulative for corftainers 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: -z— gallons Total Capacity for Site: Z Z o gallons Comments: EHD Inspector: Date: B—T-y Initial: By Entered Date: By Initial: S a/ *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