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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 f of Facility Ad ess: City: Inspectio h v� .71Dat 0 � FA#: PR M Program Element: 70 6 era 24 30 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. TI/ O,SI ~fqr�� Tank (2820) ❑ #of Containers: Containers (2821) -TA `-�-- 1Product Type: 0 Total Capacity: 00 gallons (per tank or cumulative for containers by product type) Install Date: l;� �" #of Containers: . TA#• Off! -iq I ank (2820) El Containers (2821) 2 5 = Product Type: , Oy Total Capacity: gallons (per tank or cumulativeforwntamers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: T((A��#: DV 1-7 9 712 8 Product Type: D t- - ) Total Capacity: J S� gallons z (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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: .l7 gallons Total Capacity for Site: 3 (� gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: , 1,�1 1, By Initial: 'r D *Aboveground storage tank means a tank that has thecapacityto 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