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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 k ' Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd Ml ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: f T' S: Page 1 of Facility Address: City: Inspe tion te• 0/ )"j Tfi FA#: PR#: Pro gra Element: 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. Tank (2820) L1 Containers (2821) #of Containers: IT #: 1 Total Capacity: ' pOD gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: '❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5Total Capacity., gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: ® gallons Comments: t 3-Z 6 5 EHD Inspector: L Reviewed ` Date: Entered Date: By Initial: �A�► )1-,c�-00� 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. EHD 28-01 AST SURVEY FORM 09/12/08