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0 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 �- 0 - �`— Facility Address City: A Inspection te: YY z2� � ��G�� 7 FA #: I 22'7 PR #: Program leme t: � � 2- Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 2_1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. C1J�Tank (2820) El Containers (2821) #of Containers: TA#: S 1 Product Type: Total Capacity: 1-0gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: T #: 2Product Total Capacity: '1000 gallons Type: (per tank or cumulative for containers by product type) Install Date: 1 0,1'ank (2820) ❑ Containers (2821) #of Containers: T �A 015- 3 3 Product Type: Total Capacity: allons (per tank or cumulative for containers by produc type) Install Date: #of Containers: TA#: 2P6�Igzq ❑ Tank (2820) L1 Containers (2821) 4 Product Type: i /IW57-� Total Capacity: 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: r f b gallons Total Capacity for Site: gallons Comments: 0 1/2-0 EHD Inspector: Reviewed Date:Q� �,� By Initial: �, �A- 0 I Entered Date: By Initial: e 13,1d 4 *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