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' x 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: L r) � Page of Facility Address: City: Ins ecti n Dat 2,/ 40e0S -- § TO IV fd 2g FA#: PR M Program Elemen 19 c 43 Ll IT �v�a$ 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. Cif/Tank (2820) ElContainers (2821) #of Containers: TA#: 1 Total Capacity: 2 f D Ballo Product T e' (per tank or cumulative for containers by product type) install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers byproduct type) Install Date: ElTank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers byproduct 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: / gallons Total Capacity for Site: .a gallons Comments: 'W p EHD Inspector: Reviewed Date: Entered Date, By Initial: By initial: `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. EHO 28-01 AST SURVEY FORM 09/12!08