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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.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page / of � Facility Address: City: Inspection' nspection Date, 07 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. EP/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type:Total Capacity: 'Cn C �� gallons (per tank or cumulative for cont finers by product type) Install Date: ED/Tank(2820) ❑ Containers (2821) #of Containers: , TA#: 2 Product Type: Total Capacity: 10 r) 0 0 gallons (per tank or cumulative for containers by product type) Install Date: Er-Tank (2820) El Containers (2821) #of Containers: TA#: 3 1 3 S Product Type: Total Capacity: gallo (per tank or cumulative for con ers by produc Install Date: El-Tank (2820) ElContain s (2 1)�� #of Containers: TA#: e ) 4 _ dC� Product Type: 1J i�Z/ 42 (2 i l� Total Capacity: allons (per tank or cumulative for cSAt Hers 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: r, gallonsTotal Capacity for Site: gallons Comments: lai- o� EHD Inspector: , /� Reviewed Date: Entered Dat - By Initial: _ By Initial: B : 31,2911 1 "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 AST SURVEY FORM 09/12/08