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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: 7 6 Page of Facility Addrress: City: /Z (2k- Inspectin Date (2,7 FA #: PR #: 1 06-3oy1 Z� P"--.-„, Flement,-, 50 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: TA#: t9A- 19 8.7 42 1 Product Type: C a��— ) Total Capacity: Gt OO _gallons —�-� (per tank or cumulative for containers by product type) Install Date: 9ank (2820) El Containers (2821) #of Containers: TA#: [}�� ( S 2 Product Type: Total Capacity: 500 gallons (per tank or cumulative for containers by product type) Install Date: LR' Tank (2820) ❑ Containers (2821) #of Containers: TA#: U $ 3 Product Type: Total Capacity: S 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 Total Capacity for Site: l D gallons Comments: 7- EHD Inspector: Reviewed Date: By Initial: 1-Zj) Entered DatW31,9 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