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w, x SAN JOAQUIN COUNTY w ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax. (209).46873433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: p Page /of L Facility Address: 1 rtyInspects ate: jqA FA M PR#: Program ent E 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: ,o,,,,� Total Capacity: gallons -- -_ - — (per tank or cumulative for containers by product type) I nstall Date: F-1Tank (2820) L/ Containers (2821) #of Containers: _ TA#: 2 Total Capacity: 5 j Product Type: —L��pji`�I _ gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ 'Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: `gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821)---.jof 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 Data: Total Capacity this Page: Q r o gallons Total Capacity for Site: p� gallons Comments: o rRd A/U/ i � — ., bvlz - EHD Inspector: �,^ Reviewed Date: Entered (� Date: By Initial: tt �4 By Initial: ti *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, i EHD 2s-ot AST SURVEY FORM D9H 2108 r