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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: t T q r t Y- ITb Page ofFacility Address: a Cit, y' Inspe_ction Date:FA#: r1t uJ � 7�'I`i �y -I , I ]_�_Rrk Program Element: 'a Tank/Container Information Completefor-aN-site-9witth cumulative aboveground storage of petroleum 21,320 gallons in tanks' and containers"". Complete one box for each tank or each cumulative container product type. lt�Tank (2820) ❑ Containers (2821) #of Containers: TA#: rr � Product Type: ( ) Total Capacity: { gallons (der tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: /` gallons Total Capacity fo-r,S te: �jL � gallons Comments: EHD Inspector: y,t Reviewed Date: Entered Date: L, V By Initial: S,l�, By Initial: "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more p oleum. *`Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM