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SAN JOAQUIN COUNTY U. ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 r"elephone: (209) 468-3420 Fax: (209)468-3433-Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: / f5- Page / of Facility Address: City: Inspectio p I , _ D�� on1'', 17v/ FA#: PR#: Program Ef men p 530 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks`and containers". Com fete one box for each tank or each cumulative container product type. nk {2820) ❑ Containers (2821) #of Containers: 1 7 Product Type.,T"`: Total Capacity: J, 0 D gallons YP (per tank or cumulative for containers by product type) / Instal! Date: 0 Tank (2820) 13Containers (2821) #of Containers: STA#: 2 gallons Product Type: Total Capacity: .. ., (per tank or cumulative for containers by product type) Install Date: El Tank (2820) 9�Containers (2821) #of Containers: TA#: 3 Total Capacity: Product Type: p y: �_� r� gallons (per tank or cumulative for containers by product type) Install Datta: ❑ 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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: f LP gallons Total Capacity for Site: 9/0 gallons Comments: EHD Inspector: Reviewed ,y Date: 7ntered Date: By Initial: A �.��t , 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 ;l AST SURVEY FORM 09/12/08