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• 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.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: } Page -5 of Facility Address: City: Ins ctlon ate: �o� Rd . �-a ro FA PR#: Program Element: 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#: ZZ6-1 12 1 Product Type: Total Capacity:' �� gallons - (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 9containers (2821) #of Containers: 1 TA#: 2 Total Capacity: 00 gallons Product Type: D d e) (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 3 Total Capacity' gallons Product Type: w 1 (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) [Containers (2821) #of Containers: �- TA#: &571 q 7 Q 7 4 Total Capacity: I kallons Product Type: �!.o ni y (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) XContainers (282 1) #of Containers: �_ TA#: 5 Product Type: ` Total Capacity: _2�� gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2Q gallons Total Capacity for Site: gallons Comments: EHD Inspe Reviewed Date: Entered Da#e: By Initial: By Inkial: ,� D ovegr n storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. **Conte eans a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM