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4� y _ 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 Facility Name: } F S� Page of Facility Addres : Citf.. Inspection E) FA IPR#: Program Element: A V 'E 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. ank (2820) ❑ Containers (2821) #of Containers: TA#: Total Capacity: sy 2 a gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: Product Type: .[ p y: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: E 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install late: ElTank (2820) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type:. (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #ofContainers: TA#: 5 Total Ca acit Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: I Total Capacity this Page: D gallons Total Capacity for Site: p gallons Comments: t i EHD Inspector: Reviewed Date: Entered Date: By Initial: L.:l-�b-()� By Initial:,_ "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more oY petroleum. ! "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08 'A