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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: # 6r'F/C / r Page �_ of .� L )/t;' F Facility Address: City: Inspection Date: `t- z FA #: PR #: 6�� 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. ank (2820) ElContainers (2821) #of Containers: TA#: 1 l Total Capacity: gallons Product Type: % 4,ae�u,�� (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons 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 y: gallons Capacity: p Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: z gallons Total Capacity for Site: gallons Comments: EHD Inspector:Reviewed Date: Entered Date: By Initial: By Initial: Lt f wvvegivu"U arviage Cann 11leariS a tanK that nas the capacity to store bb gallons or more of petroleum. **Container means a storage device designed to be moved when full. EHD 28-01 09/12/08 AST SURVEY FORM