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SAN JO _ - AQUIN COUNTY ENVIRONMENTAL HEA "Ai-�n�K LTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:.(209)468-3433 Web:Www.sjg0v.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Mame: Facility Address: Page ( of{�. _�i 8572" Inspection Date: FA#: �IQ PR#r '� t-0 Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers`*. Com lete one box for each tank or each cumulative container 6roduct type. /ff Tank (2820) ❑ Containers (2821) #of Containers: l TA#: 1 Total-Capacity: 4Mgallons Product Type: �( [ {per tan r cumulative for containers byproduct type) ^� - Install ©ate: i ontainers: ❑ Tank (2820) Containers (2821) #of CI TA#: 2 Total Ca gallons Product Type: _ t 1 (per tank omufatfiefo=rc4rs �y pro ; Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: ' 3 Product Type:. Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: i ❑ 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 Type: Product T Total Capacity: 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: Reviewed Date: Entered Date- By Initial: ,10 By initial: /. *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. EHp 28-01 _ 09/12/08 AST SURVEY FORM i%