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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: C o T M /a E- 8 - s Page of Facility Address: City: Inspectic Da d nl fl v9 FA It: PR#:O r3 D ProgrAm E 1. ,\ l '713 cJ 2 U 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. V-tank (2820) ❑ #of Containers: TA#:Containers (2821) b 1 Total Capacity: 3 S gallons Product Type: �1-�.r D (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TAM 2 `nn Total Capacity: � Product Type: 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: TAM 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: O gallons Total Capacity for Site: gallons Comments: EHDInspector: Reviewed Date: Entered Date: By Initial: wt,) By Initial: �✓ fl 9 '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. EH0211-01 09/12/08 AST SURVEY FORM