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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: ASLO OWyI O&Z U( . !�- V Page �_ Of� Facility Address: City: Insp ction Date: -70S 41-t6*I Awe- FA#: PR#: Pro ram EI ent: L 11-9 s ! 19 1? 84'0 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. ❑ Tank (2820) Containers (2821) #of Containers: I TA#: 1 Product Type: O p/Z Total Capacity: _ L�_ gallons (per lank or cumulative tot containers by product type) Install Date: ❑ Tank (2820) )rContainers (2821) #of Containers: TA#: 2 Total Capacity: r 5� gallons Product Type: PABA � -7'tj1'Nh/ ---L (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: 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 or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: Product Type: p y: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for site: gallons Comments: EHD In or, Reviewed Date: Entered Date: U By Initial. v . „( I!`ct-I By Initial. bovegro nd storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. t "Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM