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SAN JOAOUIN 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 E" ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page Of AlO'er S m City: n Dat :01 Facility Address: Inspe ti rA FA#: PR M Program Ele ent: 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 tyee. Tank (2820) IQ Containers (2821) #0i"Containers: h TA#:p oduct Type: 1 Pr � � a ----- Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: I. ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 er Product Type: �/2r/4?i, A//,) I Total Capacity: _�lTy gallons (per tank or cumulative for containers by product type) E' Install Date: ❑ Tank (2820) El Containers (282'1) #ofContainers TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Ins talI Date: ElTank (2820) ElContainers (2821) #of:Containers: TA#: I. I 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) l nstal I Date: . ElTank (2820) ❑ Containers (2821) #of!Containers: TA#: E• 5 Product Type: Total Capacity: gallons (per tank or cumulative For containers by product type) I ns#al I Date: Total Capacity this Page: 20- gallons Total Capacity for Site: gallons t r 0 Comments: S s Chu - E: EFiD Inspector. C s Reviewed ;; Date: Entered Date: By Initial: �'t'�`7` Bylnitial: J� �( *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. EHQ 28-01 AST SURVEY FORM 09112108