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SAN aJOAQUIN 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 Auovegiound storage tanix means a tank that has the capacity to store 55 gallons or more o pet eum. 'Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM Facility Name: Page i- of " Facility Address: / ,- � A1TZI �f City: �, inn c- Inspection Rate: ; J FA #: PR #D , Program Element: _ f&q'L 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) i Containers (2821) #of Containers: TA#: 1Product Total Capacity: //`) gallons Type: �✓ /J j //r�= j !� (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) @'Containers (2821) #of Containers: ` TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for ontainers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 - - , Total Capacity: _ gallons Product Type: (per tank or cumulative for containers uy 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: 2,1110 gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed By in Date: Entered Dat�- By Initial: �Ak_� Auovegiound storage tanix means a tank that has the capacity to store 55 gallons or more o pet eum. 'Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM