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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: 0 v �/� r M Page `, of l Facility Address: City: Inspection Date: FA #: PR M Program Element: DS�� _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. VTank (2820) ❑ Containers (2821) #of Containers: r TA#: 1 Total Capacity: 0(1 0 gallons Product Type: P'n ) (per tank or cumulative for containers by product type) Install Date: M/f ElContainers #of Containers: TA#: Z96-113 ank (2820) (2821) �^ 2 Total Capacity: gallons Product Type: _b2;,� , (per tank or cumulative for containers b roduct type) /Tank(2820) Install Date: #of Containers: TA#: L�,� $� g Et El Containers (2821) 3� Total Capacity: ZZ,.� gallons Product Type: �-� c (per tank or cumulative for container's by product type) Install Date: ❑ Tank [g/1 #of Containers: TA#: 0 6 (R'7 o—p (2820) ontainers (2821) 4 c• Total Capacity: 5 gallons Product Type: tti f , 51-,k (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 2 g 0 gallons Total Capacity for Site: < - �� gallons Comments: EHD Inspector: �. Reviewed By Initial: Date: t; ,2 9-o� Entered Date: 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