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t • 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: A/1). �" / [n/ G PagEent; Facility Address: A /-yam - / city Ins� / PR#. Progr 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. Id Tank (2820) ❑ Containers (2821) #of Containers: TA#: Q51 '7'49 1 Total Capacity: / 0 d 01> gallons Product Type: _(per isnk or cumulative for containers by product type) Install Date: M Tank (2820) ❑ Containers (2821) #of Containers: TA#: -7)1 2 Total Capacity: '3 n 0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: Ll9 3 Product Type: /iUi2S?G e l� Total Capacity: gallons (per tank or cumulativeF containers byproducttype) Install Date: Q"Tank (2820) ❑ Containers (2821) #of Containers: TA#: /L6-1-7 W 4 Product Type: Iq / 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: ) gallons Total Capacity for Site: gallons Comments: EHD Ins p % Reviewed Date: Entered Date: By Initial: By Initial: *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 09/12/08/08