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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: A 5 SlZ Page Of Facility Address: City: _ / Inspecti n ate: o �NG ! :. �S Z Aoi FA M. #: Program lement: 7 3 Tank/Container information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks*and containers'. Complete one box for each tank or each cumulative container product type. ank (2820) ElContainers (2821) #af Containers: TA#: 1 Total Capacity: 3 J"6 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: €Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: it / 2 Total Capacity: 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 byproduct type) Install Date: ElTank (2820) ElContainers (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#: i_ 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: r gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: ! By Initial: 11�1ry 1�. �•eel I By Initial: "`Aboveground storage tank means a tank that has the capacity to store 55 gallons or more bf petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08