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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: Z Page / of J— Facility Address: City: Inspe tion ate: -'73tr a r_- � Z . too 0 FA#: PR M Program Element: 3 2� 4/-() Tank/Container Informal Complete for all sites with cumulative aboveground storage of petrok m t1,3 g Ilons in tanks'and containers". Complete one box for each tank or each cumula ve cont ner roducttype. ❑ Tank (2820) d Containers (2821) #of Containers. /fA#: 1 Product Type: % 0 Total Capacity: / / � gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: , TA#:: 2 Total Capacity: ti I"? gallons Product Type: ata A J (per tank or cumulative for�tainers byproduct type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3Product Type: �TI� Total Capacity: � @ 0 gallons (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: gallons Total Capacity for Site: rl gallons Comments: 4 0 N r EHD Inspecto Reviewed Date: ,,p� Entered Date: By Initial: 'a.-\i-0 1 By Initial: B- B '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