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_ SAN JOAQUIN COUNTY Y- NVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:wwi f.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE ;PROGRAM SURVEY FORM Facility Name: o G Page —j—of NA Facility Address: City: Ins pectioatqO : r-4 7 FA#: PFM Program Element; Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container roduct type. 4 ank (2820) ❑ Containers (2821) #of Containers:. �TA#: Q 1 Product Type: rr d< 0 Total Capacity: O gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers:- TA#: 2 Total Capacity: %� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: k ElTank (2820) ❑ Containers (2821)' :#of Containers: TA#: 3 Product Type: Total Capacity: gallons o (per tank or cumulative for containers by product type) Install Date: I ElTank (2820) ElContainers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type:, fi (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: gallons Total Capacity for Site: p gallons Comments: t - EHD Inspector: Reviewed Date: Entered Date: By Initial: V_� By Initial: Ex *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 4. AST SURVEY FORM OB/12108 i