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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: d3/ A 911hlPage _4 of Facility Address: City: Inspection Date- 2- 1 1 fl/ FA#: fP R#: Program le nk: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroieum 21,320 gallons in tanks*and containers**. Com fete one box for each tank or each cumulative container producttype. Tank (2820) ❑ Containers (2821) #of Containers: TA#: !7 1 -- Product Type: ,S Total Capacity: U gallons (per tank or cumulative for containers by product type) Install Date: .E Wank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: 3 gallons _ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#. 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ❑ Containers(2821) #of Containers: TA#: 5 Total Capacity: __ gallons Product Type: (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: ,4j v1)'0-0('\ 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. EHO 28-01 AST SURVEY FORM 09/12/08 i