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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: Page % a � of . Facility Address: city: l 5 773 - Lon/ar TRr--E 6& Inspection ate: r FA #: PR #: o Progra Element: -z -g3 n 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) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: Lo gallons F� Product Type:- (per tank or cumulative for containers by product type) Install Date: a Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5,5 ( 14-j 2 Total Capacity: r C gallons Product Type: yp (per tank or cumulative for containers by product type) Install Date: 12/Tank(2820) ❑ Containers (2821) #of Containers: TA#: $ ZI 3 rProduct Total Capacity: > (I� gallons Type: Gr S (per tank or cumulative for containers by product type) Install Date: C/Tank (2820) El Containers (2821) #of Containers: TA#: �5 I B 4 7 4 Total Capacity: �d �� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: _� TA#: 5 Total Capacity: 5S gallons Product Type: ' (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 gallons Total Capacity for Site "�� ) gallons `} Comments: EHD Inspector: Reviewed Date: By Initial: -Zp-00A Entered Date: By Initial: 15/ -Rb *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. l **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08