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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.tjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE. PROGRAM SURVEY FORM Facility Name: I Page 1 of Facility Address:'[' t� City: Inspect! n Da e: FA#: PR#: Program Element, 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 tyee. VTank (2820) ❑ Containers (2821) #of Containers: c1TA#: 1 A S b Total Capacity: _gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: #: 2 Product Type: Total Capacity: gallons _iT�J (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 Total Capacity: gallons Product Type.- (per ype:(per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers- TA#: 5 Total Capacity: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: ' O 0 gallons Comments: EHD Inspector: , Reviewed Date: Entered Date: By Initial: VA q-q_0 I 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. EHD 28-01 AST SURVEY FORM 09/12/08