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I 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: Page ofM V&P OY y LN/M 0 . Facility Address: City: Inspecti n ate: p q �2 () FA#: PR#: Program Eleme t: PA 0 D Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum X1,320 gallons in tanks"and containers". Complete one box for each tank or each cumulative container producttype. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 _&A Total Capacity: gallons Product Type: st (per tank or cumulative for containers by product type) Install Date: ElTank (2820) ❑ Containers (2821) #of 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#: 4 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) 'Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: i (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for site: -7-00gallons Comments: fl� EHD Inspector: Reviewed Date: Entered Date: C]` By Initial: �,0 By Initial: D l "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