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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: / Page of - G- D O //✓� __z _ Facility Address: i/Nc-A N A;u City: Inspectio Date•. D FA #:R PM Progr Ele ent: 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) El Containers (2821) #of Containers: TA#: D 3 1Product Total Capacity: .7S© gallons Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: "/ DSO 2 Total Capacity: � 5' gallons Product Type: (per tank or cumulative for containers by product type) Install Date: GYfank (2820) ❑ Containers (2821) #of Containers: RA#: /951-1 3 Total Capacity: 61-() gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El #of Containers: TA#: d O Tank(2820) L" Containers (2821) _Z 4 Total Capacity: o gallons Product Type: (per tank or cumulative for contai ers by product type) Install Date: ❑ Tank (2820)%r/Containers (2821) #of Containers: T>>A#: /96 j1,0 5 f / Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: �b gallons Total Capacity for Site: Z/91F gallons Comments: G P. 0 Al / (y1, %��" % -r `Y EHD Inspector: r Reviewed` By Initial: AA� Date: 2 V - ` U-�- L Entered By Initial: Date: "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more bf petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08