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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: tiC ; ��Giyrzj , Page of Facility Address: City: Inspection' Date: — u1c �QPCUALy w awic va yaiivnb or more OT petroleum. **Container means a storage device designed to be moved when full. / EHD 28-01 09/12/08 AST SURVEY FORM -UL FA #: M1 PR #: , (1 Programlament: '" ,5-34-, 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) ❑ Containers (2821) #of Containers: TA#: ©5a 1 Total Capacity: � ��_ gallons Product T e: , r � S -;/L Yp (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: D K gallons Product Type: Yp ' V `0 _ (per tank or cumulative for containers by product type) Install Date: Z'' ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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: P Y� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: _; gallons Total Capacity for Site: _ gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: a *Ahnvanrnunrl cfnrn— f-1, — u1c �QPCUALy w awic va yaiivnb or more OT petroleum. **Container means a storage device designed to be moved when full. / EHD 28-01 09/12/08 AST SURVEY FORM