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SAN JOAQUIN COUNTY is 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 of Facility Address: 21�! /��/� r✓T/�GA City: -, N f Inspection Date- � '/' 6- J FA #: PR #: Program I e 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. IV/Tank (2820) ❑ Containers (2821) #of Containers: TA#p: 1Product Total Capacity: -5'Q: , gallons Type: (per tank or cumulative for containers by product type) Install Date: Lid Tank (2820) ❑Containers (2821) #of Containers: , TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: In/Tank (2820) ❑ Containers (2821) #of Containers://�� TA#: 12 3 Total Capacity: gallons �� Product Type: %/l� (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: /9 fj-%29 V/Tank (2820) ❑ Containers (2821) 4 Total Capacity: gallons Product Type: I,.2/� � I � 121 (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 gallons Total Capacity for Site: Z Foo gallons Comments: � A L C'2- 11 j 22 EHD Inspector: Reviewed By Initial: Date: Vry 01.\�j Entered By Initial: Date: l 4 D *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