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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 Addre s: /Pity: Inspect n Date:, �l7 2,/a 21-9-65 T s / l FA #: PR M Program e 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. Bank (2820) El Containers (2821) #of Containers: TA#:112,1 11196) 1 Total Capacity: 0 0 0 Product Type: � 1�s � gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: 2 U Tank (2820) ❑ Containers (2821) Product Type: Total Capacity: '�+-t'r� gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: / TA#: ❑ Tank (2820) E Containers (2821) + 3 Product Type: oRd Total Capacity: �_r gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: El Tank(2820) ER Containers (2821) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 5Product � Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: % gallons Total Capacity for Site: gallons Comments: /C/& J S J EHD Inspector: Reviewed Date: By Initial: �- ( Entered Date: By Initial: 07#pt? *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more df petroleum. Y **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08