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I SAN JOAQUIN COUNTY ` £ENVIRONMENTAL HEALTH DEPARTMENT 600 East MainStreet, Stockton, CA 95202-3029 Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUMSTORAGE PROGRAM SURVEY FORM Facility Name: , L �~ 'Fr' Page of Facility Address: City: Inspe i n ate: �0A r o FA#: PR#: Program ent: 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: r Total Capacity: gallons b`-`� �•1 —' (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type). Install Date: El Tank (2820) ElContainers (2821) #of Containers: TA#: 5 1Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: r` Total Capacity this Page: gallons Totalcapaicityfor Site: gallons Comments: d EFID Inspector: Reviewed :Date: Entered Date: By Initial: •lit By Initial• *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. fj "Container means a storage device designed to be moved when full.. EHD 28-01 AST SURVEY FORM 09/12108 }