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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 Name: Page '-- of < Facility Address: C' Inspecti n Date; 1 FA #: PR #: -S �? -' Program Ele ent: 30 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#:�� gyp% 1 Total Capacity: 21-, � gallons Product Type: /`'' z) (per tank or cumulative for containers by product type) Install Date: O Tank (2820) Containers (2821) #of Containers: TA#: o� 2 Total Capacity: l_ �'rr� gallons Product Type: /'V �' �J -� (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers #of Containers: TA#: (2821) 3 Total Capacity: C &� ' ') gallons Product Type: fig 1V5-) (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: ❑ 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 FTotal Capacity for Site: gallons Comments: EHD Inspector: Reviewed By Initial: Date: Entered Date: By Initial: n r%U0VegF0U iu swidge tanK means a tanK inat has the capacity to store 55 gallons or more of petroleum. f **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08