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e SAN JOAQUIN COUNTY ` . ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name L o �" ��s A�P, 3 q~ Page - N of Facility Address: City: Inspection 'pate: Q i �12 _ r r FA M PR MProgram ement: 1�o Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks"and containers"*. Complete one box for each tank or each cumulative container product type. VTank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Product Type: r Total Capacity: gallons ----- (per tan or cumulative for containers by product type) Install Date: VTank (2820) ❑ Containers (2821) #of Containers: y� TA#: 2 Total Capacity: gallons. tProduct Type: (per tank or cumulative for containers by product type) Install Date: E ❑ Tank (2820) ❑ Containers (2821) #of Containers: TAM Total Capacity: gallons Product Type: (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: I ❑ 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: 5- gallons Total Capacity for Site: gallons Comments: i EHD Inspector: Reviewed Date: Entered Date;2r) y l By Initial: By Initial: '�?) "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of Oetroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08