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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East MainStreet, 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—4 of Facility Address: City: Inspection fDateO FA#: R#: Progra lem f PW Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2:1,320 gallons in tanks"and containers" Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: r, 1 Total Capacity: 3 , a gallons Product Type: f S X (per tank or cumulative for containers by product type) Install bate: k (2820) El (2821) #of Containers: TA#: an 2 ' Product ype: l� 1 Total Capacity: _gallons (per tank or cumulative for containers by product type) Install-Date: ❑ ank (2820) ❑ Containers (2821) #of Containers: TA+#: i 3 _3,J_0 Product Type: Total Capacity: gallons (per tank or cumulative for Containers by product type)' Install Date: f 1 #of Containers: TA#: ❑ Tank (2820) ❑ Containers (2821) 4 Product Type: Total Capacity: gallons I (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers:, TA#: 5 Total Ca acit Product Type: p y: gallons (per tank or cumulative for containers by product type) . Install Date: Total Capacity this Page: gallons Total Capacity for Site: �� gallons " .. Comments: EHD Inspector: Reviewedi Date: TEntered Date: C t3y Initial: �N 5-IR-0*1y Initial: ar "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. END 28-01 "AST SURVEY FORM 09/12/08