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SAN JOAQUIN COUNTY L LNVIRONMENTAL 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: I U I'C C i Page __/ of / Facility Address: City: Inspection Date: FA #: PR #: Progra €fie n� J r Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks* and containers**. Complete one box for each tank or each cumulative container product type. /' M Tank (2820) ❑ Containers (2821) #of Containers: TA#: r9,-5_/ c7 B g(Q 1 Total Capacity: r 7 0 �' gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Ea/Tank(2820) ❑ Containers (2821) #of Containers: TA#: �g6h qB 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: Olif) gallons Product Type: (r z� S (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: S (ro gallons Total Capacity for Site: �r S gallons Comments: EHD Inspector: n d -, Reviewed By Initial: Date: �� Entered Date: By Initial: g Lol *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