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SAN JOAQUIN COUNTY rt ''"'" .. N NVIRONMENTAL 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 Nam :Z-A 0 r4 Page /. of Facility Address: sty: Inspects Dat FPR#: Program Ele f r7 o 70 A#: f Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks`and containers`" Complete one box for each tank or each cumulative container product type. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: /� o O gallons Product Type: A 7 (per tank or cumulative for containers by product type) install Date: ❑ Tank (2820) Vcontainers (2821). #of Containers: _ TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: E � #of Containers: _ __ TA#: El Tank (282Q) �'Contair�ers (2821) -- 3 Product Type: Total Capacity_: gallons (per tank or cumulative for contai ers by product type) Install Date: CS Containers 2821 #of Containers: jTA#: ❑ Tank (282Q) ( ) 4 Total Capacity: I� S gallons Product Type: , IAIA 7` C21 I/ (per tank or cumulative for containe y product type) Install Date: El Tank (2820) 11Containers (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#or Site: 1�1 gallons I Comments: 2� 3 LT19 - f4 rl% I EHD Inspector: Reviewed Date: Entered Date: C (•� By Initial: t� �_fl By Initial: p 49 *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more o petroleum. i *"Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12108 i