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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 i3Ii �� p Page -"/— ofy Facility Address:� City: Inspectio D� :�� FA #: M PR #: I DSS Prografn Element: Z K20 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. U Tank El Containers #of Containers: TA#: � (2820) (2821) 1 � Total Capacity: �gallons Product Type: A V 4 (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Total Capacity: � gallons Product Type: (per tank or cumulative for con ainers by product type) Install Date: #of Containers: TA#: ank42820) ❑ Containers (2821) 3 Total Capacity: gallons Product Ty, (per tank or cumulative for con ainers by product type) Install Date: #of Containers: TA#: 661 T� ank (2820) ❑ Containers (2821) 4 '7 Total Capacity: gallons Product Type: 4iz�� % (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5Product Total Capacity: gallons Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Q gallons Total Capacity for Site: S3 gallons Comments: EHD Inspector: Re viewed Date: By Initial: rj .�� 'i Entered Date: By Initial: B *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