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SAN JOAQUIN COUNTY "ENVIRONMENTAL HEALTH DEPARTMENTS 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 L of 2 Facility Address: City: _2e .Q Ins tion Date: F #: L PR#: i 2� /� P gra lement: Tank/Container Information 3Z 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 Droduct type. R�Tank (2820) ❑ Containers (2821) #of Containers: TA#: 05/70a—'O 1 Product T e: Total Capacity: /�- 00(7 gallons YP � d �yza°-� (per tank or cumulative for wntainers by product type) V Install Date: &?/Tank (2820) ❑ Containers (2821) #of Containers: TA#: O5/��(� 2 Total Capacity: /'jp 0 Q gallons Product Type: ETank nk or cumulative for containers by product type) Install Date: nk (2820) El Containers (2821) #of Containers: TA#: 2� Capacity: 25� gallons Product Type: pl _A- ( e •/ nk or cumulative for wntainers by protluct type) Install Date: nk (2820) ❑ Containers (2821) #of Containers: TA#: Q5/272� Capacity: Product Type: P t, O 0 gallons nk or cumulative for containers by product type) Install Date: nk (2820) Yontainers (2821) #of Containers: � TA#:Capacity: / gallons Product Type: ®j k or cumulative for containers by product type) Install Date: Total Capacity this Page: 30—7(�0 gallons Total Capacity for Site: Comments: �� gallons _ �3 5 EHD Ins ector: Reviewed Date: Entered Date: By Initial: rj.�-I,{) By lnitial: 'A ve nd storage tank me a tank that has the capacity to store 55 gallons or more of petrole�. D "Co ainer means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM