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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 N lb Page –I—of _ Facility A drrasss: 1 Inspection (Date: /� FA#: PR#: Program Element, 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. �bTank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: Product Type: gallons f/1/Al (per tank or cumulative for contain rs y product type) va 7 Install Date: / 'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: S gallons Product Type: (per tank or cumulative for containers by product type) Install Date: L&CA�A lZ14 Tank (2820) ❑ Containers (2821) #of Containers: TAM 3Product Type: ' s�fn Total Capacity: gallons I � e (�v (per tank or cumulative for containers yproduct type) Install Date: LA ASk / Tank (2820) ❑ Containers (2821) #of Containers: TA#: Total 4 Total Capacity: --_� —gallons Product TypT: —t my 000 -r4p (per tank or cumulative for contnt m rr yproduct type) Install Date: ��t Vv 1 Tank (2820) ❑ Containers (2821) #of Containers: TAM 5 Total Capacity: -�(t� g Product Type: ? allons 1 . _ ,� n/A (per tank or cumulative for containersb product type) I,Q7�""vi k!r'I VvwS ✓� Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons o Comments: EHD Inspect 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. EHD 28-01 AST SURVEY FORM 09/12/08