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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: x Page —� of Facility Address: City: Inspection Date: FA #: FA Doo & PR #: - ProgramElement: �R,• �7� s 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#: X6_19 g' ' 1 _ Total Capacity: gallons Product Type: - (per tank or cumulative for containers by product type) Hn1 Install Date: t✓u�— 5 �f Tank (2820) ❑ Containers (2821) #of Containers: TA#: 05'/ R 7 (q 2 Total Capacity: _ z�=`� _ gallons Product Type: ;,ts, f (per tank or cumulative for conraineib uy p—juct type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: � S / `Ian � 3 Total Capacity: S5� gallons Product Type: ��- / (per tank or cumulative for containers by product type) Install Date: l r ej2LA-12 4h Tank (2820) ❑ Containers (2821) 0— ( a #of Containers: TA#: $ 702 j 4 Total Capacity: S5'� gallons Product Type: 4% (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: _051 R 7 0��— 5'— Product Type: C> / Total Capacity~ gallons : (per to or cumulatye fof contain rs y product type) Install Date: Total Capacity this Page: -. tJ'�, Lti gallons Total Capacity for Site: �- J d S gallons Comments: ' U $- EHD Insp or: Reviewed Date: ,�p� By Initial: �.'�j. � 1 Entered By Initial:Ve Date: y r� veground 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