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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: --TA S Page / of Facility Address: City: Inspecti n Dat , FA #: R #: Program Element: zg3C 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. EN Tank (2820) ❑ Containers (2821) #of Containers: TA#: _ 5 1 Total Capacity: gallons Product Type: (per tank or cumulative for containers 6y product type) Install Date: /Tank(2820) ❑ Containers (2821) #of Containers: TA#: D S 2 Product Type: Total Capacity: �� gallons (per tank or cumulative for c6ntainers by product type) Install Date: #of Contain----- Tank (2820) El Containers (2821) 3 .., �j Product Type: �'✓�i S �` �� G S Total Capacity: L gallons (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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: Z '� gallons Total Capacity for Site: Z gallons Comments: EHD Inspector: Reviewed Date: By Initial:a -L4-0 Entered Date: By Initial: Lf *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