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SAN JOAQUIN COUNTY "VIRONMENTAL 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: l N o rL C kL, �r "S or�j- 2e r�{ C f4r�id--% Page of Facility Address: City: Inspe tion D te: 30 A/� UN4 o� �� S�dc1Gh� !2 Z/ �U�i FA#: PR#: — Prog am Element: 2 9 3 2 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. !'r Tank (2820) ❑ Containers (2821) #of Containers: TA#: 96-1 1 Product Type: �/ e-s�(, five L Total Capacity: DU 6gallons (per tank or cumulative for corftainers by product type) Install Date: U IQ 9: +' M X Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9�►�'�g3 2allons Product Type: W#A Pte.- O +Z- Total Capacity: � g U� (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: B 3N V� D I`L, d L(Qyid Total Capacity: � gallons Product Type: - (per tank or cumulative for containers by product type) Install Date: U n V-ti L" ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: S-16 gallons Total Capacity for Site: gallons Comments: EHD Inspe Reviewed Date: Entered Date: By Initial: tv�J { �.,1. 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