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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 Name: D,1:5 c r Page of Facility Address: r C'ty Inspectio Date: FA #: PR M ,30 Pro ram Element. Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks* and containers**. Completfa one box for each tank or each cumulative container product type. El Tank (2820) Containers (2821) #of Containers: TA#: c3� 1 Total Capacity: / / P gallons Product Type: N y 0 g© LI G o ) (per tank or cumulative for containers by product type) Install Date: n Tank (2820) ElContainers (2821) #of Containers: TA#: n !g '7 2j-� Total Capacity: % gallons Product Type: l�'/� J% (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (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: 100 gallons Total Capacity for Site: gallons Comments: EHD Inspector: y Reviewed Date: Entered Date: By Initial: By Initial:) Q' huUveyrouno 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