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SAN JOAQUIN COUNTYdo ~ ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGEPROGRAM SURVEY FORM Facility Name: C�l� l V111/1-�Y /ZD A Page of Facility Address: City: Inspectio . FA#: PR#: Program El ent: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers". Cam fete one box for each tank or each cumulative container product type. EY/Tank (2820) ❑ Containers (2821) #of'Containers: TA#: 1 Product Type: Total Capacity: Sao gallons .0-4 olla% - • _ -� (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type' . (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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) Install 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: 4Q gallons: Total Capacity for Site: �' gallons Comments: EHD Inspector: ip Reviewed Date: Entered Date: (� By Initial: ,� �:'�_�� . By Initial: "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleu . "Container means a storage device designed to be moved when full. EHD 28-01 : r. AST SURVEY FORM 09/12/08