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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 a nay nanw. `� - — 2— Page --j— of 2 - Facility FacilityAddress: ( L ��Cl C� ✓�7�i� City: � 1 t-�r � Inspection Date: FA #: PR #: Program Element: 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. f� Tank (2820) ❑ Containers (2821) #of Containers: TA#: 1 Total Capacity:allons Product Type: l� - (per lank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ZContainers (2821) #of Containers: TA#: 2 (: Total Capacity: � � gallons Product Type: C' i 16 > (per tank or cumulative for containers by product type) � � Install Date: ❑ Tank (2820) 'Containers (2821) #of Containers: TA#: 3 Total Capacity: C3 11L P Y� gallons Product Type: - 6 Le a � ,1, (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) IJ -Containers (2821) #of Containers: 4 Total Capacity: 1 �- . gallons Product Type: -?;� M,0 (per tank or cumulative for containers by product type) �- Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: p Y� gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: By Initial: Entered Date: By Initial: r. VVIZ;yWUHu 5101ciyu IanK 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 09/12/08 AST SURVEY FORM