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` SAN JOAQUIN COUNTY C .. 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: �� S Page of Facility Address: /' City: Inspec ion ate: Za Z G Ss 0 FA#: PR M Program Element. 1 ? 4/_1 7 rz a Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers". Com tete one box for each tank or each cumulative container product type. LWTank (2820) ❑ Containers_ (2821) #of Containers: TA#: 1 Product Type: �S Total Capacity: � gallons (per tank or cumulative for containers by product type) Install Date: E #of Containers: TA#: [J' Tank (2820) El Containers (2821) 2 Product Type: Total Capacity: 5" gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ElContainers (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: El Tank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) I nstail Date: i Total Capacity this Page: 1000 gallons Total Capacity for Site: /� gallons f Comments: EHD Inspector: Reviewed Date: Entered Date: Y By Initial: �_pC/1 By initial: *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. EHp 28-01 AST SURVEY FORM 09/12/08 x