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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: Saiz / — fr Page il?� of Facility Address: City: Inspec 'on Dat 6o2 S . /�FLC AU -- FSCAL©i✓ 91z�>0 FA#: PR#: n Progra� t:Z7 159�54 , 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. 11 Tank (2820) ontainers (2821) #of Containers: TA#: LFq/112 Iq� 1 Product Type: ,�g?ot� 9f Total Capacity: •�Q gallons (per tank or cumulative for containers by product type) Install Date: ElL� Tank (2820) 'Containers (2821) #of Containers: TA#: 2Total Ca acit �,� Product Type: p y: gallons (per lank or cumulative for containers byproduct type) Install Date: El Tank (2820) L7 Containers (2821) #of Containers: TA#: 4Qc0Er 9i�S' 3 Product Type: lyAs T -z Total Capacity: gallons (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 orcumulative forccotainers by producttype) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Pager '7, O gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By By Initial: By Initial: 9 *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 09/12/08 AST SURVEY FORM