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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 it of IKE Facility Address. City: Inspection Dar) FA C PR M Program Element: 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. LQ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 69,,S-)q I l 1 Product Type: S Total Capacity: -5 gallons (per tank or cumulative for containers by product type) Install Date: EZ`Tank (2820) ElContainers (2821) #of Containers: TA#: N,S/ l l 2 Total Capacity: gallons Product Type: r��f (per tank or cumulative for containers by product type) Install Date: © Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: (l/r-q f �� Total Capacity: Z rd gallons (per tank or cumulative for containers by product type) Install Date: 2"Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4p) Product Type: ,fiC�G�2 Total Capacity: T gallons (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: -q C) gallons Total Capacity for Site: J gallons Comments: EHD Inspector: v Reviewed Date: Entered Date: C/ By Initial: VA dip- By Initial: ';1/17/'P?y *Aboveground storage tank means a tank that has the capacity to store 55 gallons or more o petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08