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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.sigov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page Z of v Facility Address: City: Inspection Date: ^ FA #: PR #: Pro ram Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks' and containers". Com le, , one box for each tank or each cumulative container type. product ank (2820) i Containers (2821) #of Containers: TA#: 6 / q"I0 a 1 Total Capacity: %L� gallons Product Type: /�,q f i % / /7V (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) l/ Containers (2821) #of Containers: % TA#: _E51'93`3 3 2 Total Capacity:gallons Product Type:15' (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total y: gallons Capacity: p Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: gallons Product Type: (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: % J gallons Total Capacity for Site: gallons Comments: EHD Inspector: 1-16 > Reviewed Date: By Initial: Entered Date: By Initial: rkuovegFOUnd storage xanK 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 09/12/08 AST SURVEY FORM