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r+/ SAN JOAQUIN COUNTY �0 ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page of Factli Address: City: Inspec)I p to: 2 0 �!1 py6e FA#: PR#: '� 53a IS� Program7iD m t: Tank/Container Information Complete for 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 tal Capacity: 3 no gallons Product Type: C7�4 S (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TSA#: 2 Total Capacity: '3 rV gallons Product Type: . Lc1Ya� (per tank or cumulabve for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: T #: 3 Product Type: Total Capacity: :, . v gallons (per tank or cumulative for conrainers by product type) Install Date: ❑ Tank (2820) idicontainers (2821) #of Containers: __L__ TAM Total Capacity: � � 4 r gallons I/ Product Type: WR> J t D/ y (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: 1 S gallons Total Capacity for Site: 0-1 gallons Comments: ,v EHD Inspector: Reviewed Date: Entered Date: By Initial: -)A-rj� By Initial: Ec 7 *Aboveqround storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. "Contaer means a storage device designed to be moved when full. EHD 28-01 _ AST SURVEY FORM 09/12/08