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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.orglehd t ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page of rN d E ` Facility Address: City: Inspection Datg:A 1 2.S a L.r_ /Z1 4� J PR M. Program Element, Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2,1,320 gallons in tanks* and containers". Complete one box for each tank or each cumulative container product t e. ank (2820) ❑ Containers (2821) #of:Containers: TA#: 1 Total Capacity: gallons Product Type: /T� JZ (per tank r cumulative for containers byproduct type) Install Date: Tank (2820) ElContainers (2821) #of Containers: ®A#: 2 Total Capacity: ll-� gallons Product Type: f (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of.Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ElTank (2820) 1:1Containers (2829) #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: gallons Total Capacity for Site: gallons Comments: Z ©y -� - r� oG //O G r EHD Inspector: ; Reviewed Date: Entered Date: By Initial: By Initial: { *Aboveground storage tank means a tank that has the capacity to stare 55 gallons or more df petroleum. t *"Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08