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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.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page of�_ Facility Address: City: Inspectloo Datev 6 o r9 �5 c M11 h/ S T D G/x:��7Oli✓ ! ly FA#: PR M Program Element: 31 R 3o z. Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 0 0 0 gallons Product Type: Total Capacity: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: l 0 0 p gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ntainers (2821) #of Containers: TA#: o� 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) P< ontainers (2821) #of Containers: T-,A�.#: 4Product Type: /�' 114 Total Capacity: S:5' gallons (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: 2� �% gallons Total Capacity for Site: gallons Comments: 2 tq 0 -)r EHD Inspector: } Reviewed Date: Entered Date: By Initial: OI. Ib O� By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more pe roleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08