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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: D te: 1Inspection 7Q1i% �� V � C L� �l /4 FA #: PR M ProgramElement: D� ©7-1 ,e 3 .�2_ 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. 'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: 7>1Total Capacity: O 000 gallons (per tank or cumulative for containers by product type) Install Date: %Tank(2820) ❑ Containers (2821) #of Containers: TA#: 2Product Total Capacity: 00 v gallons Type: (per tank or cumulative for con ainers by product type) Install Date: -0 Tank (2820) Xcontainers (2821) #of Containers: /0 TA#: 3Product Total Capacity: `J �O gallons Type: IV Oar j%/� (per tank or cumulative for containers by product type) Install Date: KTank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: asOZ/ Total Capacity: / c50 gallons (per tank or cumulative for containers by product type) Install Date: El Tank(2820) ElContainers (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: d _ l gallons Total Capacity for Site:(� gallons Comments: 012i 2,P// �/, EHD I ector: Reviewedn' Date: By Initial: U 1_ 2 Zb l 3 Entered Date: By Initial: 1 *A r tnd storage tank means a ank that has the capacity to store 55 gallons or more of petroleum. ** on ner means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08