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s 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.orglehd ABOVEGROUND PETROLEUM STORAGE-PROGRAM SURVEY FORM Facility Name: in jy Page�� of Facili Address: City: Inspects D a V S !sl FA#: PR#: Program E �1- 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, 4 { Tank (2820) ElContainers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: (per tank or cumulative for Containers by product type) Install Date: I a B'Tank (2820) ❑ Containers (2821) #of Containers: TA#. 2Product Type: Total Capacity: 2--a B gallons i IT (per tank or cumulative for containers by product type) i Install Date: ElTank (2820) 13Containers (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) #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: Q gallons Total Capacity for Site: v d gallons . Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: r .ttl b� Byinitial: ��l 917 "'Aboveground s orage 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 09112/08 T ,. AST SURVEY FORM