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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: ( `6-4 Page _, of Facility Address: City: Inspection Date: 6� L FA#: PR#: �\ 3 Prog� menta 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: I TA#: D 5o2DDi 1 J Product Type: �T Y V\S (/U Total Capacity: � gallons DI (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ,Containers (2821) #of Containers: TA#: 00rz5-� 2 Total Ca acit ' Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) D-Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: —?- gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 0'Containers (2821) #of Containers: U TA#: .OfS'a P19lQ 4 Product Type: ATE ,Q�C/`�� Total Capacity: gallons - (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 2"Containers (2821) #of Containers: TA#: [2�o2F�DLo 5 Product Type: �)� �5.1U -1. `� n Total Capacity: � ,� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: 5 1 gallons Comments: 1 ILI i, EHD Inspect Reviewed Date: Entered Date: r� By Initial: 1 � 1 N By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleu "Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM