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Y r SAN JOAQUIN COUNTY s _7" 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: H 6 (-y C S Page of t �. Facility Address: City: Inspecti Date, 1 Z b 0 lil/ h/ Tic, l'G Z 97o,� FA#: PR M Program Element: b' Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum al,320 gallons in tanks*and containers" Complete one box for each-, ach tank or each cumulative container product type, t ank (2820) 11Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: 7_/0 gallons ....__ (per tank or cumulative for containers by product type) install Date: E ° ElTank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Ca acit Product Type: p y: 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: E E ❑ 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: gallons .Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: / gallons Total Capacity for Site: �1 gallons Comments: Z a:. EHD Inspector: Reviewed Date: Entered Date: By Initial: 1i.� 8y Initial: 1 `� v *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of pe roleum. *'"Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08