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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE 'PROGRAM SURVEY FORM Facility Name D L Page __Lof Facility Address: IY/ City: Inspectio ate: 7 !i 109 FA#: PR#: Progr m lement: '�5 6 �o _Z19 4�D 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. r Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 � Product Type: Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: L`7 Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: _ - �D � gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers:' TA#: . 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Instal! Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Data: By Initial: kp.A �,��.0 By Initial: C p "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 09/12/08