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%,,,0e SAN JOAQUIN COUNTY 11—� 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 till Name: L V f0 Page ,` of Facility Address: ,D City: Inspection Dat z foIL//---9 &W ` (7� -z9-�7 FA M PR M Program Element: GzZv2 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum al,320 gallons in tanks` and containers". Complete one box for each tank or each cumulative container Broduct type. #of Containers: Tank (2820) El Containers (2821) TA#: 1 Total Capacity: -ffa gallons Product Type: �,�g (per tank or cumulative for 66fitainers by product type) Install Date: ❑ Tank (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 Total Capacity: gallons Product Type: (per lank 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: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: d� gallons Total Capacity for Site: `�� gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: VA By Initial: *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleu **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08