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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: , /� /� S % 24 Page / of v Facility Address: 0 City: -?5—R1 Inspectjon afe:, FA #: PR #: Prog�/rrallllm Element: Z$ 0 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. 2- Tank (2820) El Containers (2821) #of Containers: TA#: 02 1 Total Capacity: 10 7� gallons ,,�� Product Type: /rl� -� S (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: ,5-1 I EVTank (2820) ❑ Containers (2821) 2 � 0 & Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: �nk (2820) El Containers (2821) #of Containers: TA ��JR oZ� o 3�, �d Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: S Tank (2820) [1 Containers (2821) #of Containers: TA#: �9� 4) Total Capacity: gallons Product Type: / (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 0"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 P:. (/ L-) �3J gallons Total Capacity for Site: Z() (� gallons Comments: T- EHD Inspector -A Reviewed Date: By Initial: �.�D.p� Entered Date: By Initial: /0 D `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