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W .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: FI S Cr/� - Page -/ of / Facility Address: City: Inspection.Date, :; IV✓ - WT tv 0 FA#: PR#: Program Elem nt: / 214 - 8 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2:1,320 gallons in tanks* and containers**. Complete one box foreach tank or each cumulative�container product type. , 21 Tank (2820) ❑ Containers (2821) #of Containers: TA#: Product Type: Total Capacity: D gallons li jI(per tank or cumulative for containers by product type) Install Date: l r El Tank (2820) El Containers {2821) #of Containers TA#: r 2 ,= Product Type: Total Capacity: gallons (per tank or cumulative for contasners by product type) Install Date: ;I E, ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: . (per tank or cumulative for containers by product type)' Install Date: 11 Tank (2820) El Containers (2821) #of Containers: TA#; Capacity: Product Type: Total Ca p y: gallons ;l(per tank or cumulative for containers byproduct type), Install Date-. ,i ElTank (2820) ❑ Containers (2821) #of Containers: TA#: 5 ii Product Type: • Total Capacity:: gallons � .. �. . y - (pertank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons_ Total Capacity for Site: gallons Comments: r�i I � :i EHD Inspector: Reviewed Date: Entered Date:_ By initial: 4-1q,00� I-Byinitial: *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 I oo AST SURVEY FORM 09/12/08 it