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. YNVIRONMENTAL SAN JOAQUIN COUNTY 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: � N�� " Page __L of Facility Address: o City: Inspection Da r - h� S7` o FA#: PR#: Progr 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 tyee. WTank (2820) ElContainers (2821) #of Containers: TA#: 1 Product Type:. I Total Capacity: gallons " (per tank or cumulative for containers by product type) Install Date: f ank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: J gallons Product Type: -� /` (per tank or cumulative for containers by product type) Install Date: W l� lYU"' i` ank (2820) L►� Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: #of Containers: _�_. TA#: Tank (2820) 14ontainers (2821) — - 4 Product Type: l�y� t''ib dl Total Capacity: gallons — — (per tank or cumulative for containers byproduct type) Install Date: �- ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tante or cumulative for containers by product type) Install Date: h Total Capacity this Page: 6 gallons Total Capacity for Site: D gallons C Comments: EHD Inspector: Reviewed Date: Entered Date: F By Initial: $,��- By Initial: )r "'Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of pe roleum. O� "*Container means a storage device designed to be moved when full. a EHD 28-01 AST SURVEY FORM 09/12/08