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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: Q Page of Facility Address: city: Inspectio�rDate: a 5 2�C R 61 / / r) FA Z�X PR#: n6a9�l Prog L m 6 �n(/ Tank/Container Information yVj 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 • "31 q�� 1Product Type: Total Capacity: U gallons 4.4 (per tank or cumulative for contai ers by product type) Install Date: LJ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 9L5-1<'q'��_ 2 Total Capacity: ��00 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type:T (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ET-Containers (2821) #of Containers: TA#: 49,6-) 4 //--f Total Capacity: 1—� 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: v/ (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: (C gallons Comments: i EHD inspector: Reviewed Date: �p Entered Date: ✓/ By Initial: tj'D� By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of p troleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08