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it 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 r ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: A N Page --/—of Facility Address: :! City: Inspectio Da P 02FA#: PR#: Program le ent. �I 65�D 8 D t Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks*and containers'". Com lete one box for each tank or each cumulative container product type. Ef/Tank (2820) C] Containers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: I! k (2820) ❑ Containers (2821) #of Containers: TAM an 2 Product Type: 4r�T Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: U/'ran (2820)f° El Containers (2821) 3 Total Capacity: U gallons Product Type:'. (per tank or cumulative for containers by product type) Install Date: I'. 11 Tank (2820) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: i ElTank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: r Total�C, acity this Pager gallons, Total Capacity for Site: gallons Com ents: i; t EHD Inspector; / Reviewed Date: Entered Date: By Initial: By Initial: /1�7 "'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 09/12108 FI.