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SAN.iOAQUIN 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: S Fa ility Address: Page of City: ins ction ata: M.FA#: PR � f /_ Pr gra/r�n Element: 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. El Tank (2820) . El/containers (2821) #of Containers: TA#: 1 Total Capacity: �I gallons Product Type: (per tank or cumulative For containers by product Itype) Install Date: ❑ Tank (2820) Vcontainers (2821) #of Containers: TA#: 2 Total Capacity: 4� gallons Product Type: _ (per tank or cumulative for containers byproduct type) Install Date: ❑ Tank (2820) 'Containers (2821) #af Containers: TA#: Q 3Product T e Total Capacity: � gallons • YP ' (per tank or cumulative for containers by product type) Install Date: i #of Containers: TA#: ❑ Tank (2820) ❑ Containers (282 1) 4 Product Type: Total Capacity: gallons - (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) I nstall Date: Total Capacity this Page: 2 gallons Total Capacity:for Site: 20 gallons Comments: Q�L /D D p —00 EHD Insp Reviewed Date: Entered Date; By Initial: kA4 'S S•l By initial: "Abovegr� r u torage tank means a tank that has the capacity to store 55 gallons or more of pe roleum. "*Container means a storage device designed to be moved when full. EHD 28-01 08/12!08 AST SURVEY FORM