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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: FOD 0 A Yl/ G /V U Page _.� Of Facility Address: City: Inspectio Date: FA #: tn [ -3 U' c) PR #: Program El . 1 / 4 D 3 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. 9" Tank (2820) ❑ Containers (2821) #of Containers: TA#: Z 1 Total Capacity: 0 cl 0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: al ank (2820) ElContainers (2821) #of Containers: TA#: o'Z� 2 Total Capacity: r 0 0gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 011"Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: lrl% gallons Product Type: (per tank or cumulative for C6ntainers 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: j �� gallons Total Capacity for Site: 545 gallons Comments: EHD Inspector: �, J Reviewed , ,^( Date: Initial: V By V 4.b Entered Date: By Initial: 1� ) t7L&z— *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