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0 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: Page / of Facility Address: City: Insp ction ate: z S z, Al, 6 Lc) ssd X73 0 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, CjYTank (2820) ❑ Containers (2821) #of Containers: TA#: 1Product Type: Total Capacity: $'OC� gallons (per tank or cumulative for containers by product type) /' Install Date: a Tank (2820) ❑ Containers (2821) #of Containers: TnA#: 2 Product Type: D Total Capacity: 50 o gallons (per tank or cumulative for containers by product type) 1 Install Date: tJ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3Product Type: Total Capacity: .S�D0 gallons (per tank or cumulative for containers by product 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: / gallons Comments: r A-F'r ><1 S T N141 EHD Inspector Reviewed Date: ,) Entered Date: By Initial: — Z —O t' 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