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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT l 600 East Main Street, Stockton, CA 95202-3029 1 l Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM �s Facility Name- ZZ Page of 1 s _L_ Facility Address: city: Insp c ' n te: o LI/ 2/� 0 9 FA #: PR M Program Element: D0 2,2 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. Tank (2820) ❑ Containers (2821) #of Containers: TA#: �J 1Product Total Capacity: S 0 p gallons Type: ,%�,.�,v_�� �.� (per tank or cumulative for containers by product type) Install Date: E Tank (2820) ❑ Containers (2821) #of Containers: TA#: (� 2 Total Capacity: > /Y-0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 11fank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: J �� gallons Product Type: r' (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: /� gallons j Total Capacity for Site: / �'vfY� gallons Comments: EHD Inspector: Reviewed By Initial: Date: • b Ql Entered Dat I By Initial: -Aboveground storage tanK means a tank that has the capacity to store 55 gallons or more of petroleur-0. **Container means a storage device designed to be moved when full. i A EHD 28-01 AST SURVEY FORM 09/12/08