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SAN JOAQUIN COUNTY y 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)ff /V C/ Page __,L__ of Facility Address: City: Inspecti n Dat : /J !;LIS � 2, O FA#: PR M Pr6gralm EI t: �� 05j0 �5" 2 �' Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks`and containers". Complete e box for each tank or each cumulative container product type. d Tank (2820) ❑ Containers (2821) #of Containers: TA#:_ 06-11? /q Q'D 1 Product Type: Total Capacity: gallons n /,' (per tank or cu r con ainers by product type) Install Date: I-R40 w)9 Ipo t✓ 14/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1-9 2 Product Type: Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: M/tank (2820) El Containers (2821) #of Containers: TA# ©,,tT/ I o� 3r Product Type: Total Capacity: J €-0 gallons f/�/�p (per tank or cumulative for containers by product type) Install Date: f t/ // 2/Tank (2820) ❑ Containers (2821) #of Co TA#: 1 4Product Type: F'4� Total Capacity: S� gallons W� �n (per tank or cumulative for containers by product type) Install Date: (Tzr Cnk (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: -7 5 � gallons Product Type: � (per tank or cumulative for containers by product type) Install Date: 11VA CrAtil Total Capacity this Page: 2,�S gallons Total Capacity for Site: Z ^/ 5o gallons Comments: a EHD Inspector: Reviewed Date: DD Entered Date: By Initial: 0`, �`J By Initial: GY '6�L `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