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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 7�4 i, a O6r- /'/zT-soa %lelzis ��s Page — of—/ Facility A d ess: City: Inspection Dade: r FA#: PR#: Program Element: L 6 -a 0(-3,5 z 3�' 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. ❑ Tank (2820) 1:1 Containers (2821) #of Containers: TA#: 06-) 2,? 7 1 Total Capacity: / O C) (-) o gallons Product Type: Z2,j i (per tank or cumulative for containers by product type) Install Date: P/Tank (2820) ❑ Containers (2821) #of Containers: TA#. l 2 ,� Product Type: Total Capacity: � �� 0 zgallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 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: 2 �� (,�C� (� gallons Total Capacity for Site: Zl� 4 00 gallons Comments: EH do etor: Reviewed Date:� Entered Date:—� By Initial: 'k 0� By Initial: B *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