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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 e: E f 2o�r)L Page of Facility(f rS F . 4A2&(hR-J City: i62,1 lo�aq�o FA M `.'l PR M• Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) Xcontainers (2821) #of Containers: F TA#: 1 Product Type: Uq��h_ 15) Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 11Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: ' 3 Total Capacity: gallons Product Type: a (per tank or cumulative for containers by product type) Install Date: I ElTank (2820) ElContainers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: f ❑ 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: gallons. i Comments: fi ii r EHD In ctor: Reviewed A4 Date: Entered Date: By initial: �..��OA 8y Initial: jFj Q, "Abovegrdbnd 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 i