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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: U � Page I of Facility Address: 0 City: Inspe tion Date,. FA #: q PR M - Program Eleme t: .� '3 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: _9 ' TA#: _tg,S 1 Total Capacity: gallons Product Type: 1141D z e4 0. (per tank or cumulative for conTaine&lby product type) Install Date: El Tank (2820) [Zontainers (2821) #of Containers: TA#: 5$ 2�� Product Type: Total Capacity: — �� gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 2/ ontainers (2821) #of Containers: TA#: l9, 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: 67 Total Capacity: / % gallons (per tank or cumulative for containers by product type) Install Date: #of Containe " : TA#: 115 j ElTank (2820) Containers (2821) 5 -� Product Type. dI% Total Capacity: / gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: S 2 gallons Total Capacity for Site: ` gallons Comments: Aa �� r✓� 3 Z°y- EHD Inspector: �D ' Reviewed�, ,im"^, Date: By Initial: V�•� Entered Date: By Initial: 3 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!08/08