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v SAN JOAQUIN COUNTY v 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 Ad ress: City: Inspectir Date: 5'c9 r 1 0 ✓t r/D � a FA#: PR#: Program Element: , 72 ? r J Tank/Container Inforination 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. LIYTank (2820) ❑ Containers (2821) #of Containers: TA# 1 Total Capacity: ' �') gallons Product Type: (per tank or cumulative for containers by product type) Install Date: MzTank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: L TO gallons Product Type: LQ (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (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 Total Capacity: gallons Product Type: (per tank orcumulative 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: 91-6 gallons Comments: �d EHD Inspector: ReviewedDate: Entered Date:l G �y By Initial: and1 t.N-t7h By Initial: J '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