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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.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM FAName: L Page -of 3 F : City: Inspe tio(n�D e: F /tJ t6 PR#: Program Element: a 2 � Tank/Container Information 3 Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks'and containers**. Com fete one box for each tank or each cumulative container product type. ❑ Tank (2820) Containers (2821) #of Containers I TA#: -LaU l 1 Product Type: �✓�o Total Capacity: �,�gallons yp A�l �� M�/(f� (per tank or cumulative for containers by product type) Install Date: \l1Vll ❑ Tank (2820) k Containers (2821) #of Containers:0-16i" I ? TA#: p 2 Total Capacity: _ 167 S gallons Product Type: 0-1 O i" 'V11 Z ` lui% �( (pertank orcumulative for containers by product type) Install Date: �Q (� 1 ❑ Tank (2820) #of Containers: TA#: d IeQ ( ) Containers (2821) 3 Product Type: 0q Total Capacity: [b gallons yp n blZ. l!I (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 tyProduct Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative forwntainers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: 2=7�Z7 gallons Comments: EHD Ins tor: Reviewed /t , Date: Entered -- ----- --.-- By Initial: ' " Date: By Initial: /p O 'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. t `*Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM