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T " SAN JOAQUIN COUNTY t. y 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: Inspec� 79 an IVE l 0^� FA#: PR M Program Element: V ILI Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum al,320 gallons in tanks*and containers**. Complete one box for each tank or each cumulative container,product tXRe. VTank (2820) ❑ Containers (2821) #of Containers: TA#: Q 1 � y gallons Product Type: Total Capacity: - - -• (per to or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2Product Type: Total Capacity: -0 gallons (per tank or cumulative for containers by product type) Install Date: ElTank (2820) 2 containers (2821) #of Containers: TA#: G 3 Total Capacity: 110 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: � #of Containers: TA#: El Tank (2820) Cd"Containers (2821) 4 � Product Type: Total Capacity: gallons (per tank or cumulative for contain rs by product type) Install Date: ❑ Tank (2820) ey Containers (282 1) #of Containers: 7i TA#: 5 Product Type: U o S 7-,F- (per � C {/ Total Capacity: J J � gallons - ••- (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: ! Z? gallons Total Capacity for Site. , Z ? gallons Comments: 'Z o —• `Y - Z3 EHD Inspector: Reviewed Date: Entered Date: By Initial: `, ,� It X4-0 By Initial: n *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. D **Container means a storage device designed to be moved when full. EHD 28-0f 09/12/08 AST SURVEY FORM