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SAN JOAQUIN COUNTY T 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 �A P- 4 (3Q� d �eG Stee, U41A S : �-tL� Page-L of Facility Address: City: ®� Inspect n Date 61 FA#: D � � PR#: Progra Element: 29 _`iLfI 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: f TAM 1 Product Type: _euD C)y re. Total Capacity: 10ob gallons I (per tank or cumulative for Zontainers by product type) Install Date: Tank (2820) E1 Containers (2821) #of.Containers: TA#: &a 2 Product Type: .6 A10 f 205— ?1 I-Lit)6) V� Total Capacity: U gallons (per tank or cumulative for containers by product type) Install Date: 3 Tank (2820) Containers (2821) #of Containers: TAM 1`7 3 Product Type: Total Capacity: gallons (per tank or cumulative for c6itainers by product type) Install Date: ❑ Tank 2820 Containers 2821 #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for c&6jnete by product type) Install Date: ❑ Tank (2820) ElContainers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: f Total Capacity this Page: gallons Total Capacity for Site: O gallons I Comments: I . 4 I EHD Inspector: Reviewed Date: Entered Date: By Initial: `} .��,.6� By Initial: *AbWe—gFounk 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 09/12108