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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 N- C of / Page / Facility AddreRs: City.. Inspection9ate: FA#: PR M Program Element: l) C► %9 119 -03 --1--a- —,--S! -�� 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. U"Tank (2820) ElContainers (2821) #of Containers: - TA#: 1,4T I ` 1 Total Capacity: i C) �> 0 C'Y gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ontainers (2821) #of Containers: �L�` TA#: 2 Total Capacity- / s p y: c. gallons (per tank or cumulative for contain rs by product type) Install Date: "nk (2820) ❑ Containers (2821) #of Containers: TA#: r�sl ` ,?J32 3 Total Capacity: _.l gallons Product Type: (per tank or cumulative for containers by product type) Install Date: EP Tank (2820) ❑ Containers (2821) #of Containers: TA#: z11 y 4 Product Type: Total Capacity: ,, �� ) gallons (per tank or cumulative for containers by product type) Install Date: eTank (2820) tainers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: /e;1 e� e? gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: / gallons I Total Capacity for Site: / gallons Comments: EHD Inspector: L Reviewed Date: Entered Date: By Initial: �,�Q-l� By Initial: 21C/ *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