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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: d lJ L F D Page -Z- of Facility Address: City: Ins pe on ate, FA#: PR M ProgramElement: `)l 0 d Z- $ o 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. P-Tank (2820) ❑ Containers (2821) #of Containers: TA#:`, 1 Product Type: (Yfi S 4 Total Capacity: SD-0 gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (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 Product Type: Total Capacity: gallons (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: j—" gallons Total Capacity for Site: 1-06 gallons Comments: EHD Inspector. Reviewed1 . .\ Date: Entered Date: er '� By Initial: �X4 By Initial: `Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of p ro eum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09112/08