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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Z' Telephone:(209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page r Of l Facility Address: City: Inspecion Da 6 2 S �vly >�rPR 0 FA#: #: Progr m Element! 6 s 6)�6aU 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) ElContainers (2821) #of Containers: TA#: 1 Total Capacity: �� gallons Product Type: _ S X (per tank or cumulative for'containers by product type) Install Date: /Z Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 .L� Total Capacity: gallons Product Type: " (per tank or cumulative for con ain s by product type) Install Date: ElTank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: El Tank (2820) ElContainers (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 fj Comments: EHD inspector. Reviewed Date: Entered Dale: By initial: •t�.�� By Initia{: W Oc019 *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 09112/08