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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.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page _ of Facilit Address: City: Inspection Date: ��i < 1 C {) FA#: PR#: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks"a:51itai Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) 2'Containers (2821) #of Containers: I TA#: ©pe-10�) 1 Total Capacity: gallons Product Type: _��ii 4e_' C) ( (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) P'Containers (2821) #of Containers: TA#: �� a� Ip6rz� / 2Product Type: S� TVj l Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) �Containers (282 1) #of Containers: TA#: �f; ,� 2 3 Product Type: Total Capacity: b 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: - Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: / i L,�!?a. —{ } ,f Total Capacity: �C��(j gallons --t — (per tank or cumulative for containers by product type) ( � Install Date: Total Capacity this Page: �a gallons Total Capacity for Site: 1 7 l 3- gallons Comme-P s: r EHD Inspector: Reviewed Date: Entered Date: U By Initial: y 3 I G) By Initial: / `Aboveground storage tank means a tank that has the capacity to store 515 gallons or more of pe oleum. "Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM