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SAN JOAQUIN COUNTY 40 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 Facilitydress: 1 City,: ^�� Inspection Date: 1(0 Pvl� n ( I IWnvJIL 0 4-Z-G. ( I FAV: PR#: Program Element: 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) O'Containers (2821) #of Containers: 2 TA#: 1 Product Type: 02 Total Capacity: gallons (per tank or cumulative for on ainers by product type) • 6Yl Install Date: ❑ Tank (2820) ,ff Containers (2821) #of Containers: 2 TA#: 2Product Type: _l�d oil Total Capacity: gallons (per tank or cumulative for cont. rs by product type) Oh Install Date: ❑ Tank (2820) ,-Containers (2821) #of Containers: _�� TA#: o2D E 3 Product Type: � � — q Total Capacity: S gallons (per tank or cumulative for containers by product type) Install Date: o-C1 ❑ Tank (2820) -Containers (2821) #of Containers: TA#: �� ) 4Product Type: �✓1 Total Capacity: gallons (per tank or cumulative for containers by product type) L`� 9 Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: _ — TA#: 5 Total Capacity: gallons Product Type: W-10 r (y)� (per tank or cumulative for containers by product type) S Install Date: Total Capacity this Page: gallons Total Capacity for Site: �2LJ gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: y !I By Initial: �� 1 "Aboveground storage tank means a tank that has the capacity to st re 55 gallons or more of petroleum. C "Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY F"