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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.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE'-PROGRAM SURVEY FORM Facility Name: Page of E k o 9 A . r FacilityAddress:5 20 = City: Inspection ate: � �7zr FA#: PR M Program Element: D5 -L,g 1'l 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. k (2820) El (2821) #of Containers: TA#: an 1 Total Capacity: gallons Product Type: (per tank or cumulative for containe by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: s gallons Product Type: /r (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 D� Product Type: X9.5 7 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: El Tank (2820) El Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: t--Zig 0 gallons Total Capacity for Site: 'Z gallons Comments: EHD Inspector: 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 petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 ;I AST SURVEY FORM 09112/08 it