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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:-TA [t/ M o Page —L of Facility Address: City: Inspection Date: V/ s - 14- o FA#: PR#: Program Element: b/ r d z tJ Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2-1,320 gallons in tanks" and containers". Complete one box for each tank or each cumulative container product type. ank (2820) ❑ Containers (2821) #of Containers: TA#: 1Product Type: Iii S Total Capacity: SOS gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Product Type: ��Gl Total Capacity: A gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: 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: Q gallons Total Capacity for Site: gallons Comments: FEE A Reviewed Date: Entered Date: ' raj By Initial: wj �,�. pC) By Initial: ' (/H�7 `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