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l 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 STORAGEPROGRAM SURVEY FORM Facility Name: ., Page of Jt/ G Facility Address: City: Ins pecti Date: z S• e r 2Ts ra C, t_`� 1-2-, d FA#: PR#: Program Element: gGo -g 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. _, � #of Containers: TA#: �fank (2820) ❑ Containers (2821) a 1 Product Type: Total Capacity: gallons -- (per tank or cumulative for 65ntainers by product type) Install Date: ank (2820) LlContainers (2821) #of Containers: ` TA#: 2 Product Type:. Total Capacity: � gallons ---- (per tank or cumulative for containers by product type) Install Date: t #of Containers: TA#: 14 ElTank (2820) Containers (2821) 3 Total Capacity: gallons Product Type: ALJ 9 (per tank or cumulative for containers by product type) Install Date: ,r ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: . (per tank or cumulative for containers by product type) Install Date: i El 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: ,j gallons total Capacity for Site: gallons Comments: CARL r Z EHD Ihspector. Reviewed Date: Entered Date: By initial: 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. EHD 28-01 AST SURVEY FORM 09/12/08