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A 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: 1f g p Page / of Facility Address: city: Inspectio Date FA#: ttR . Prog a Element: g 066- b( 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 producttype. P-1-nk (2820) ❑ Containers (2821) #of'Containers: TA#: 1 Total Capacity: ��gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 6 Tank(2820) El Containers (2821) #of Containers: T�4#: 2 Total Ca acit Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: t ❑ 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 (2 821) #of Containers: TA#: 4 Total Capacity- gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ 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: Q gallons Total Capacity for Site: 9 0 gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: V to 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 09112108