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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: Page 'Z -of '7-' b% Facility Address: city: Inspect n Dat/j: ? rx— * /9/ N FA #: f Ell PR #:Progra D5o2� T 7 � en z TanidContainer 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. (2820) El (2821) #of Containers: TA#:jQ tip r� 1 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: U TA#: El Tank(2820) Containers (2821) 2 � Product Type: Li/�,5�' 0 � Total Capacity: '/1gallons (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 Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2, �� gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered ate: By Initial: By Initial: O *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 09/17/08