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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209) 468-3420 Fax: (209)458-3433 Web:www.sjgov.org/ehd _ r ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: D Page f of l oNn1 iN Facility Address: City: Inspectio Date: 0 D - �L��r:� lz. �� FA#: PR#: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks` and containers". Com tete one box for each tank or each cumulative container product type. Tank (2820) ❑ Contain #of Containers: TA#: Containers (2821} 1 Total Capacity: (7 gallons Product Type: (per tank or cumulative for containers byproduct type) Install Date: 13 Tank {2820}. ❑ #of Containers: TA#:Containers (2821) . 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 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) Install Date: I ❑ Tank (2820) ElContainers.(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: 2100 gallons Total Capacity for Site: gallons Comments: EHD Inspector: �y Reviewed Date: Entered Date: By Initial: �-apt-0,C} By Initial: *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 ii,