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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 Name: (/ U Page _/ of Facility Address: City: Inspect' Date: o s-0 ��o, �7zS�0 ; FA#: _ PR#: Program Element: l Z 3 Tank/Container Information 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. ' #of Containers: TA#: 0 S/ 7 D [Tank (2820) El Containers (2821) 1Product Type: � '9 Total Capacity: /3-0t,> gallons (per tank or cumulative for containers by product type) Install Date: ' #of Containers: TA#: l3S,/6 8 Q �. EP/Tank (2820) ❑ Containers (2821) 2 Product Type: Total Capacity: b gallons (per tank or cumulative for containers by product type) Install Date: —/ i El Tank (2820) _L� ainers (2821) #of Containers TA#: 1qz 3 Total Capacity: onl s Product Type: (per tank or cumulative for cont finer oduct 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: 2r.D O Q gallons Total Capacity for Site: ZO a gallons Comments: kV EHD Inspector: Reviewed Date: Entered Date: By Initial: � By Initial: e (/ *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