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SAN JOAQUIN COUNTY ..00 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 / Facility Address: CI Inspection/Date 135 5 9S Low foR ii3Ibi FA#: PR#: Program Element: 9 `3r71- ZY440 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 product type. Y-fank (2820) ❑ Containers (2821) #of Containers: t-� t TA#: 1Z Product Type: I/�t�0 Total Capacity: �' gallons (per 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 / Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: Z gallons Comments: ® r,.A / ONf- EHD Inspector. / Reviewed Date: Entered Date: BY Initial: (( IV,A I By Initial: /I `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. EHO 28-01 AST SURVEY FORM 09/12/08