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f 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 FacilityName: sl L-Page / of: Facility Address: City: Inspection Date:d FA#: n115A#: I'ro tann z' $e n� r 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 product type. F ❑ Tank (2820) {Containers (2821) #of Containers:�y TA#: 1 Total Capacity: 116, gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) M- ontainers (2821) #of Containers:. TA#: 2 Total Capacity: 1 / 6 gallons Product Type: ©> (per tank or cumulative for containers by product type) Install Date: L7 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3Product Type: Total Capacity: '�3 0'19 gallons (per tank or cumulative for containers by product type) Install Date: W Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: �d-V , gallons Product Type: ' 4�a/�. �� ✓ (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: gallons Comments: F 4 r EHD Inspector: Reviewed Date: Entered Date: �✓ By Initial: '1�-L�-a� By Initial: D *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 1 09/12108