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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: 10 <' �'�) �� Page —/— of�— Facility Address: City: Inspecti D te• Z r� E l�- L = T L;-�✓ � / 0 FA#: PR#: Program le ent: 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. ank (2820) ❑ Containers (2821) #of Containers: TA#: 3 1 � � Total Capacity: 7/� gallons Product Type: 2 (per tank or cumulative f Ycontainers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: ,,TAS#: /g5S(G 1� 2 /� � � Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: _� ❑ Tank (2820) 2 #of Containers: TA#: `J Containers (2821) — 3 Total Capacity ~ J Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) Ly'Containers (2821) #of Containers: TA#: / 4Product Type: Total Capacity: gallons -T--- (per tank or cumulative for containers by product type) Install Date: El (2820) ontainers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: /// 0 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 7- 2-n gallons Total Capacity for Site: Z 0 gallons Comments: - �g'C7} EHD Inspector: Reviewed Date: Entered Date: C `i/✓ By Initial: "\ 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