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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.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: �� Page � of �� Facility Address: Ci � In ti Dpte: 771" / J l l= ✓ -- FA #: PR M 6 - Program gwt:h 22 _5 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. ❑ Tank (2820) Containers (2821) #of Containers: TA#:�'� 1 Total y: gallons Capacity: p Product Type: /2/14/e (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total y: gallons Capacity: p Product Type: (per tank or cumulative for containers by product type) Install Date. - ate:❑ ElTank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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: p y: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Jf gallons Total Capacity for Site: gallons Comments: EHD Inspector: �� Reviewed Date: By Initial: Entered By Initial: Date: f) f 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 09/12/08