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.v 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: Page�of Facility Address: (� city: 5 _ G ✓ f W 0 EO J a� Inspec Dap: 1 FA#: PR M Prog am EI m n © Z 3) 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. P/Tank (2820) ❑ Containers (2821) #of Containers: _e TA#: B6/"7-7Qt--') 1 Total Capacity: 00 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: �1 -PA#: -7 7 2 Total Capacity: 4 67 0 ! gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: / -7 7 g 3 Total Capacity: 3 D d gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ 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: 20 gallons Total Capacity for Site: C) D gallons Comments: EHD Inspector Reviewed Date: Entered Date: By Initial: t_y7..0 By Initial: h `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. C7 "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08