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SAN JOAQUIN COUNTY <br />` ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM <br />Facility Name- <br />Page of / <br />Facility Address: City: <br />Inspection Date: <br />2?--� ?,- ,ca (41y ;;?� <br />-1,09 <br />FA #: <br />PR #: <br />Program Element: <br />Tank/Container Information <br />Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks* and containers**. <br />Complete one box for each tank or each cumulative container product type. <br />Tank (2820) ❑ Containers (2821) #of Containers: TA#: q <br />1 <br />Total Capacity: pa gallons Product Type: <br />(per tank or cumulative for containers by product type) Install Date: <br />V/Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1'612 542 <br />2 <br />Total Capacity: S"o-gallons Product Type: <br />(per tank or cumulative for containers by product type) Install Date: <br />`l"Tank (2820) ElContainers (2821) #of Containers: TAn#: &T) $� $ <br />3 <br />Product Type:���✓ <br />Total Capacity: 15-61 gallons <br />(per tank or cumulative for containers by product type) Install Date: rgj�ga d Al &::I AI <br />#of Containers: TA#: B <br />(b dnk (2820) Containers (2821) <br />�! <br />4 <br />Product Type:�i/i i S n� <br />Total Capacity: gallons <br />(per tank or cumulative for cuniainers . , product type) Install Date: <br />❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: <br />5 <br />Product Type: <br />Total Capacity: gallons <br />(per tank or cumulative for containers by product ty e) Install Date: <br />Total Capacity this Page: gallons <br />Total Capacity for Site: LAG C1 gallons <br />Comments: <br />EHD Inspector: <br />Reviewed Date: <br />By Initial: '1,'1� ,� <br />Entered DatWa <br />By Initial: <br />*Aboveground storage tank means a tank that has the capacity to store 55 gallons or more of petroleum. <br />**Container means a storage device designed to be moved when full. <br />EHD 28-01 AST SURVEY FORM <br />09/12/08 <br />