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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 Page of Facility Address. City: Inspection Date: FA#: ^ PR M 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#: 1 ft- j Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 f Product Type: . ��l Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: OS L Z1 I 3 70Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: r 4 Total Capacity: ) YZ gallons Product Type: (per tank or cumulative for containers by product type) r Install Date: [Si Tank (2820) ❑ Containers (2821) #of Containers: TA/#�: G i 1'121'2 5 J On Product Type: V� '�T Total Capacity: I gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 7Z gallons Total Capacity for Site: gallons Comments: tiA67 M cA f G e 8 Z`1_ate EHD Inspector Reviewed Date: Entered 1 f n Date: By Initial: � (�.'�•to By Initial: "Aboveground storage tank means a ank 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 AST SURVEY FORM 09/12/08