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e01 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: Page--L of Facility Add ss: City: Inspectio Da : 1 &. C—oLL� E/Z �� L b FA X: PR S: Program gElement. C L rd 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. ❑ Tank (2820) (Containers (2821) #of Containers: _� TAM 1 Product Type: l I� -4eV Total Capacity: �gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #Of Containers: _L _ TAM 2 �g Product Type: (2tQns�e/ Total Capacity: S 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 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: gallons Total Capacity for Site: % gallons Comments: EHD Inspector: / ) . Reviewed Date: Entered J By Initial: ulti1,0•UP\ By Initial: l« L `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