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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: , Page of S �` Facility Address: City: Inspection Date: /20 0 FA #: PR #: Program Elemen . 05a 1 2 330 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. Et Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 J Product Type: Total Capacity: �� gallons (per tank or cumulative for containers by product type) Install Date: 10/Tank (2820) ElContainers (2821) #of Containers: TA#: DJ" ( -7 2 Total Ca acit p y F o-�� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 0/'T'ai n k (2820) ❑ Containers (2821) #of Containers: TA#: r 3 gallons Total Capacity: la dr) g Product Type: �i-1rC'r (per tank or cumulative for containers by product type) Install Date: rte' Tank (2820) ❑ Containers (2821) #of Containers: TA#: , 4 Total Capacity: gallons for Product Type: L""Q �-o (per tank or cumulative co tainers by product type) Install Date: 2 ---Tank (2820) ElContainers (2821) #of Containers: TA#: 5Product Total Capacity: 3 J-17 gallons Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: S� d gallons Total Capacity for Site:3 3 gallons Comments: EHD Inspector: �? < Reviewed Date: By Initial: "l Ib. Entered Date By Initial:7 T,? *Aboveground 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