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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: /q C f��l�� ,�vs D�!/� Page of Facility Address: City: Inspei n at FA#: PR M Program Element: 3 �/ LE `30 Tank/Container Information Complee 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#: 5 r'g 7 02 1d o0 gallons Product Type: Total Capacity: f (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 2 006 Product Type: Total Capacity: gallons (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: gallons Total Capacity for Site: �� gallons 10 o-L5 Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: yyd 1.-0-09By Initial: *Abcvegroun stor ge 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