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s� 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 Nam p r J'j% --r o Page of Facility Address: City: Inspect on Date -z 9 9 ? �� = Z-' �9 FA#: PR M Progr m Elerrient. g0 l `ZbJ 96C191e 94? 2 g 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. ank (2820) ❑ Containers (2821) .#of Containers: TA#: 1 Product Type: Total Capacity: ,Spy gallons (per tank or cumulative for containers by product type) Install Date: V'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2Product Type: 'f2 Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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 curnulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: , Reviewed Date: Entered Date By Initial: Cbl _ By Initial: `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 AST SURVEY FORM OP/12/09 108 ;� � -