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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.sigov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Na �, ©N /�A N G Page of / M �A � - /1 Facility Address: City: Inspecti Da FA#: J Progra r PR#: / 7�8 OSa z Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum al,320 gallons in tanks*and containers*'. Complete one box for each tank or each cumulative container product t e. #of Containers: TA#: Tank (2820) ❑ Containers (2821) 1 Total Capacity: '5-S-0 gallons Product Type: S97 - (per tank or cumulative for containers by product type) Install Date: Ur Tank (2820) _1=1_Containers (2821) #af Containers: TA#: 2 r �^ Product Type: Total Capacity: . ,11lons (per tank or cumulative w %;-,_.. ... . ,„WUu %cpe) Install Date: /Tank (2820) ❑ Containers (2821) #of Containers: , TA#: 3 — Product Type: ca,,_ 4 Total Capacity: a 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: ❑ 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: `� gallons Total Capacity for Site`' ~ �� gallons Comments: EHD Inspector: Reviewed Daterf� Entered Date: C - By Initial: t'tq E, v I By Initial: I� *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 09112/08