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SAN JOAQUIN COUNTY YNVIRONMENTAL 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 Mfik[LL �� .� Facility Address: City: Inspecti n 7,13 S 3 IV- 199 1C1K 0 FA#: PR M W I Program Eleme t: Z7 3 a -z g'�o 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. DI/Tank (2820) ❑ Containers (2821) #of Containers: TAk 1Product Type: /)a�a� _ Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TAG #: 2 Product Type: Total Capacity: � gallons p- (per tank or cumulative for containers by product type) Install Date: ElTank (2820) 11Containers (2821) #of Containers: TA#: ` 3 Product Type: Total Capacity: gallons h (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: I Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 11 Tank (2820) E] Containers (2821) #of Containers: TA#: S Total Capacity: gallons Product Type: (per tank or cumulative for containers byproduct type) Install Date: r Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: �k •z 4 EHD Inspector: ReviewedDate: Entered Date: By Initial: --� �jl By Initial: �D *Aboveground storage ank 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 09112/08