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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 Narpe: ` Al 7.,k/Z -- S7-la Tr �l (✓ C 0' Page of Facility Address: p City: Inspecti r('atp: FA#: / PR#: Program Element: D Z 8`3 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) El Containers (2821) #of Containers: TA#: �/�c �V 1 0 gallons Product Type: Total Capacity: (per tank or cumulative fbr containers by product type) Install Date: EV/Tank (2820) ❑ Containers (2821) #of Containers: _ TA#: 2 Product Type: DA� Total Capacity: �f? r3 0gallons (per tank or cumulative for containers by product type) Install Date: ❑ 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 (2821) #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: 3 0 02 gallons Total Capacity for Site: /30 gallons Comments: EHD Inspector:�8 Reviewed Date: Entered Date L— By Initial: `�- I`� By Initial: "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more o petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 0si1 WOR