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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: 0 Page of _ Facility Address: O City: Inspection Date: 9 OD 20 D FA #: PR M Progra Element Elemen DS z "�7 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Lla'Tank (2820) ❑Containers (2821) #of Containers: TA#: D95)'F 15 2 Total Capacity: gallons Product Type: I7 (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: /9,51 3 Total Capacity: gallons T Product Type: (per tank or cumulative for containers by product type) Install Date: LB'Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Total Capacity: 0-0 gallons Z Product Type: (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) B Containers (2821) #of Containers: TA#: 5 r ly r r– Total Capacity: �—gallons Product Type: J` c� (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: j gallons Total Capacity for Site: l % gallons Comments: EHD Inspector: 7Reviewed Date: By Initial: � �. �. Entered DatV"z 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