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Sz47 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: - .. /v iD r Page of � ity: Insppectio Dat . VA FA#: — F PR#: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum �tt,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container eroduct type. Eg/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ❑ Containers (2821) #af Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: Capacity: Product Type: Total Ca p y: 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) Install Date: Total Capacity this Page: c3 0 gallons :Total Capacity for Site: S-0 gallons Comments: r EHD Inspector; Reviewed Date: Entered Date: By Initial: t�_t�-p� 8y Initial: it A►� *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 0911 WOO "