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SAN JOAQUIN COUNTY { ff *; ENVIRONMENTAL HEALTH DEPARTMENT 60Q 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--./ of Facility Address: clty:;- Ins con Date: f FA M PR#: Program Element: 22 C a o l 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. Ld' Tank�(2820) ElContainers (2821) #of Containers: TA#: • 1 Total Capacity: a2'7'�-057 - gallons Product Type: . (per tank or cumulative for containers by product type) Install Date: 2 IS/Tank (2820) ❑ Containers (2821) #of Containers: TA#; 2 Total Capacity.: �-7� gallons Product Type: _AA �/L r . (per tank or cumulative for containers by product type) Install Date: L`1 1 1 2� I Tank'(2820) ❑ #of Containers: TA#: Containers (2821) 3 - 2 Product Type: C-I o t I Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: 00 l ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821), #Containers: TA#; 5 Total Capacity: gallons Product Type: i (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity,for Site: gallons Comments: . OV 4 F s EHD Inspector: 9, Reviewed Date: Entered Date: By Initial: t,„` _1y�,J'� By Initial: Abovegr rage tank me nk that has the-capacity to store'65vgallons or more o petroleum.U ""Contains means a storage device designed to be moved when full. EHD 2a-01 09/12/08 AST SURVEY FORM