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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: n li� Z l �I` r 1� "J�/ /1�>`' �1��1 Page of Facility Address: City: Inspectio Dat l� FA#: PR#:g/ Progranh Elem n a q b Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum al,320 gallons in tanks*and containers". j Complete one box for each tank or each cumulative container product type. l�Tank (2820) ❑ Containers (2821) #of Containers: T #: 196:12 132 6 1 Total Capacity: � �� -gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: eTA#: 2 Capacity: Product Type: Total Ca y: i?-0 p gallons (per tank or cumulative for containers by product type) Install Date: E], Tank (2820) ElContainers (2821) #of Containers: TA#: o 3 Product Type: C j C / J/ Total Capacity: &f9 gallons l) (per tank or cumulative for containers by product type) Install Date: T/C^I ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: A,51 4 Product Type: Total Capacity: gallons (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: U-U f' gallons Total Capacity for Site: 2-0—" gallons Comments: EHD Inspector: fiq Reviewed Date: Entered Date: By Initial: By Initial: *Aboveground orage 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