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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 3 of Facility Address: City: Inspection Date: L�1 D I 0 FA#: Program Element: I J Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container 2roduct type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: _ A& �I � Avo Total Capacity: 21C, gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2Product 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: gallons Product Type: (per lank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z-7� C all ,� gallons Total Capacity for Site: gallons Comments: r EHD Inspeclor: Reviewe�thecapacity �tostore Entered Date: t.' By InitialBy Initial: `Abovegro d storage tank means a tank that has 55 gallons or more of petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM