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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: Cit '� Uf>>Uf Inspecti n D e: 1 / FA #: --6 PR #: Prog am E ement: Z9 1 27 _� 30 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. 11, Tank (2820) ❑ Containers (2821) #of Containers: TA#: S 5 LQ D 1 Product Type:r- Total Capacity: / ra {�(�) gallons (per tank or cumulative for containers by product type) Install Date: /Tank(2820) ❑ Containers (2821) #of Containers: TA#: _0, -Tl F ,5 Zp 1 2 c_,Product Type: Total Capacity: �) gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA#: [Tank (2820) ElContainers (2821) 3 ai Type: �i ✓ ��'� 4i Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: t Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 4 Product Type: Total Capacity: /A gallons (per tank or cumulative for containers y product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: , 5 Product Type: Total Capacity: gallons (per tank or cumulative for co nd u s by product type) Install Date: Total Capacity this Page: D gallons Total Capacity for Site: gallons Comments: EHD Inspector A / Reviewed Date: By Initial: 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 09/19/09