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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 J--- of �- Facility Address: , City: Inspectionpate* DO J 2/19 1 FA M. PR#: Program Ele t: 2Q Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 nd containers"". Complete one box for each tank or each cumulative conta* er duct t e. tet' Tank (2820) Con rs (2821) #of Containers: TA#: p — f> 1 S� Product Type: i p�. U Total Capacity: _ g s (per tank or cumulative for containers by product type) Install D � .� Tank (2820) Ey/containers (2821) # ntainers: TA#: E7 R 2 Total Capacity: _ S gallons Product T Yp �/ G (per tank or cumulative for containers by product typey Install Date: Tank (2820) ❑ Co Hers (2821) #of Containers: TA GZS; 3 Product Type: 37-4 0� Total Capacity: � gallons (per tank or cumulative+containers by product type) Install Date: Ii 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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: j Q gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: )VP q,W'F�v "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 09/12/08