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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 !, Facility Address:/'Ci " 7 J /�'� 1� c'; Inspection a n FA #: PR M Program Ele e > Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ?1,320 gallons in tanks` and containers"*. Complete one box for each tank or each cumulative container product type. / t❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: _ ,5/ �/ 4 1 Capacity: J o d Product Type: Total y: gallons p (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: Product Type: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: �� gallons Total Capacity for Site: gallons Comments: EHD Inspector. - Reviewed Date: By Initial: '� �_�0. Entered Date: By Initial: !�( 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