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g SAN JOAQUIN COUNTY U iF 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: v LA r e 1�r �C,- Page� of— Facility Address: � �� City: Inspec77.ate,n r 2 O Y 1/ FA#: PR#: Program Element: I Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks*and containers**. Com fete one box for each tank or each cumulative container product type. C�ZTank (2820) El Containers (2821) #of Containers: TA#: 1 Total Capacity: 2 r gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Uefank (2820).' F-1 Containers (2821) #of Containers: , TA#: 2Product Type: Total Capacity: .�.S d 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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (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: S gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: r�,�j-� By Initial; P_ l *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