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40 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: / Go Page of Facility Address: c City: ZZ3A� 0 Inspe�cti te: ogD�l7� FA #: S��SJ P Progra E/I m t:R0 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#: 0,�T) q a L (o 1 Total Capacity: gallons Product Type: a (per tank or cumulative for containers by product type) Install Date: Tank (2820) ElContainers (2821) #of Containers: f T #: B .S� 9') 2 Product Type: / Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers 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: 3 C) gallons Total Capacity for Site: gallons Comments: 1x1Z-6-;'09 0 G 42 Z IAIV yq #,a 7- of^^/"� c% d �iGO r" S o G A 1-J 64F TOG 7©2r-, EHD Inspector: Reviewed Date: By Initial: co_ Entered Date: By Initial: "Aboveground storage tank means a tank that has the capacity to store 55 g Ilons or more of petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08