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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 7," of Facility Address: City: Inspe tion D te: FA#: _ PR#: Pro ram Element: L19 D& 2 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: ,itr.2i► Total Capacity:/ 4-t'�U gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: /G�� gallons (per tank or cumulative for containers by product type) Install Date: tJ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 62 11130 3Product Type: Cl-'i��' �X 7 Total Capacity: 00 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: TA#: I L_ 4 Product Type: Total Capacity: -3 Cr� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) PI Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: 0 gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 42 o gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: r7 *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. oC **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 091191na