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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT . 600 East Mair'Street,.Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM ST ORAGE,PROGRAM SURVEY FORM ` Facility Name; rr� .6 Page of j Facility Address:" City: Inspection Date: r ��S PR#: P7;70Eem.nt- Completp rl b a S 2��6 - Tank/Contailnor Information 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 roduct t e. Tank (2820) ❑ Containers (2821) #of Containers: TA#; 1 Product Type: 6111. Total Capacity: �� gallons yp (per tank or cumulative for containers by product type). Install Date: ❑ Tank (2820) V6ontainers (2821) #of Containers:- TA#: 2 . Total Capacity: 1 1 0 Product Type:gallons t3tr{ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821). #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for conialners 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#: 5 Product T Total Capacity: F gallons Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: s gallons Tota!Capacity for Site:. gallons Comments: . ��r EHD Inspector. Reviewed Date: Entered Date: r By Initial: By Initial I, " "Aboveground storage tank means a tank that has the capacity to-store 55 gallons or more of petroleum. v "*Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM