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11 - 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. Facility Address: City, Page Y Inspectione• FA#: 3 /U f(PPRRM Program Elem (nt,4— /60 z- Tank/Container Information Complete for all sites with',cumulative aboveground storage of petroleum ;'1,320 gallons in tanks'and containers". P/"Tank Complete one box for each tank or each cumulative container roduct type. ltd Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: (per tank or cumulative for ntaFners product type) Install bate: Tank (2820) ❑ Containers (2821) #of Containers: TA#' 2 Total Capacity: Product Type: p y: gaPlons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ank (2820) ® Containers (2821) #of Containers: TA#: 3 -� Product Type: LIA S-rK 0 Total Capacity: y S gallons (per tank or cumulative for containers by product type) Install Date: ❑ 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) 1:1Containers (2821) #of Containers: TA#: 8 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 nate: Entered Date: By initial: -�- By initial: 17 E/ *Aboveground storagetank 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 09112toa