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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: lig ��Q J77C' , Page 0 of C�5 Facility Address: City: Inspection ate: � Al Plae �/-�1��1Vd. q ZI� 10 FA#: PR#: Program Element: X832 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. ❑ Tank (2820) XContainers (2821) #of Containers: TA#: g) 0: 'I 1 Total Capacity: C11 �� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: h 2ypProduct Te: /QV-'—Lo0 rC� y� Total Capacity: ip�� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) fGontainers (2821) #of Containers: TA#: � 3 Total Capacity: Product Type: �V -36e)131cu t'Q�✓�j gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) kcontainers (2821) #of Containers: TA#: 4 Total Capacity: Product Type: RV-4100 /eeal ��c5 gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) Containers (2821) #of Containers: _ TA#: a 5 Total Ca acity: CP �� gallons Product Type: p (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: �(P� '!�-CQ:3 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: G� jj *Abovegr nd orage tank means a tank that has the capacity to store 55 gallons or more of petroleum. GL **Contain eans a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM