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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.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name' � r s "Page of Facility Address: City: Inspection Date: FA#: �� PR#: - Program Element: d�� 8 q-0 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. P/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 �' Product Type: Total Capacity: 00 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 11 Tank (2820) ElContainers (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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: f 5 Product Type: � Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: C� gallons Total Capacity for Site: gallons Comments: { EHD Inspector: Reviewed Date` - Entered Date: P t� .� By Initial: �(� `"1 77,411\ By Initial: }. "Aboveground storage tank means a tank that has the.capacity to store 55 gallons or more ol petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08