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�..+ SAN JOAQUIN COUNTY 4=W 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 NamI'A: / 0 0 Page / of Facility Address: ity: Inspecti n Dat . zSo q- rro FA#: PRN: Program Elegy^^it: Z a 65 2 Tank/Container Information Complete fo all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks'and containers". Complete one box for each tank or each cumulative container product type. EY/Tank (2820) ❑ Containers (2821) #of Containers: TrA#: 1 Total Capacity: j jV gallons Product Type: �T J (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: -cy) gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElC� Tank (2820) ] Containers (2821) #of Containers: TAM 3 Product Type: �l� Total Capacity: gallons (per tank or cumulative for colitain0rrs k� by product type) Install Date: ElTank (2820) 9-Containers (2821) #of Containers: TA#: 4 Total Capacity: -,r gallons Product Type: 14//'S Lk' (per tank or cumulative for containers by product type) Install Date: r ❑ Tank (2820) containers (2821) #of Containers: TA#: r 5r Product Type: / Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity thie ^- / _Z "�� gallons Total Capacity for Site: / Z/ gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: \-kO By Initial: ` 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or morb of etroleur "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08