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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: . �. �; & C (9Page �_ of L Facility Address: City: Inspecti n Date: % - fill✓G K -z-V0 FA#: PR M Progr Element: bd ', �a Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers'". Com lete ne box for each tank or each cumulative container product type. ❑ Tank (2820) 2 Containers (2821) #of Containers: TA#: 1 Product Type: 1,71Total Capacity: J gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Mainers (2821) #of Containers: �^ TA#: 19 2 Product Type: //] Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) L 4-6tainers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Ems- ank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: 1� gallons (per tank or cumulative for ebritainers by product type) Install Date: El"7ank (2820) ❑ Containers (2821) #of Containers: TA#: o 5Product Type: _ 19/E 54 Total Capacity: gallons (per tank or cumulative or containers by product type) Install Date: Total Capacity this Page: J gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: ��- By Initial: 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