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SAN JOApUiN COUNTY h ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street'Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd i; ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / WS -6 A Al f Page of Facility Address: uty: Inspects Date- -f d �' o r FA#: PR#: Progr6m Ele ent: 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 type. Tank (2820) ElContainers (2821) #ofiContainers: TA#: Total Capacitygallons Product Type: : (per tank or cumulative for containers byproduct type) Install Date: , / ri U?'Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capy:acit gallons Product Type: (per tank or cumulative fo4cn noby product type) Install Date: „f ❑ Tank (2820) ❑ Containers (2821) #o#Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) I" Install Date: Irl hl El Tank (2820) ElContainers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons - (per tank or cumulative for containers by product type) i; Instal! Date: ElTank (2820) ElContainers (2821) #o#Containers: TA#: 5 Product Type: Total Capacity: gallons i, (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons I Total Capacity for Site: 40 L gallons Comments: I EHD Inspector: Reviewed Date: Entered Date: By Initial: �� ,��. ' By Initial: B *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 E AST SURVEY FORM '09112108 lis