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r 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: /✓ �_� Facility Address: City: 3 1 t Inspection Date: �. _ <_ , FA #: I-- PR #: Prograin Element: P -�_ 1� 3 o 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. 0 Tank (2820) ❑ Containers (2821) #of Containers: TA#b721,1d 1 , „ ., �, Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: O''fank (2820) ❑ Containers (2821) #of Containers: TA#: 2 r -Product Type: Total Capacity: -) /1 r0 gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) El Containers (2821) #of Containers: TA#: §,15-1 % �% 3 Product Type: T�? Total Capacity: ,� 0 rrI' gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: 71 Ll Tank (2820) ❑ Containers (2821) pp / 4 Product Type: /�i i7 .� �� '� '✓ Total Capacity: gallons (per tank or cumulative for containers byoduct typo Install Date: N -'r'a'nk (2820) On'Containers (2821) #of Containers: TA#: 5 Product Type: �� T� �zi' � Total Capacity: allons (per tank or cumulative for con a7ners by prod type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHO-Inspector L__ Reviewed Date: By Initial: 1 1 ,\� v 1 Entered Date - By Initial: m *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