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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 Nae. L.! q DA IL Page / of Facility Address: � �It�: Enspac,�iOn ate: SMO O FA#: PR M Program Element: 17 S D-a Z 8 Tank/Container information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks*and containers". Com lete one box for each tank or each cumulative container product type. 0 Tank (2820) 11Containers (2821) #of Containers: TA#: 1 Total Capacity: �� gallons Product Type: y (per tank or cumulative for containers by product typo) Install Date: II Tank (2820) 1:3Containers (2821) #of Containers: TA#: 2 I Product Type:S 2 1 Total Capacity: 3 ��gallons {per tank or cumulative for containers by product type} Install Date: ❑ Tank (2820) ❑ Containers (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: ga°lions Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) _ Install Date: 11 Total Capacity this Page: gallons Total Capacity for Site: �� gallons Comments: f a EHD Inspector: Reviewed Date: Entered Date: By Initial: �.del-01 By Initial: JTZ "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