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SAN JOAQUI1N COUNTY i A` ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.o'rg/ehd- ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Na e: .. 0 G /7 Page f of { Facility Address/: / �- City: or/ Ins pe i n Da FA PR#: Progra E e T 3 Tank/Container Information Complete for all sites with cumulative aboveground storage of petro 27,320 gallons in tanks*and containers**. Complete one box for each tank'�or each cumulative ative container product-type. Tank (2820) ❑ Containers (28.21) #of Containers: TAM 1 Product T e: Total Capacity: gallons yp + (per tank or cumulative for4104111pbye p1duct type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 'Product Type: Total Capacity: gallons -- (per tank or cumulative for containers by product type) 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: ❑ 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 Product Type: 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: � U v 3 A2- 2 J EMD Inspector: Reviewed Date: Entered Date: t. By initial: �l-(D-8� By Initial: `I W OF *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. EHO 28-01 09112!08 ' AST SURVEY FORM