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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 1' � 1M � � � ,A�N Page 1� of Facility Address: City: 0 61 Inspection Dam FA #: PR M Program Element: D 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,j� I 'A':z 1 rProduct Type: Total Capacity: .> gallons (per tank or cumulative for containers by product type) Install Date: J ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: Total Capacity: gallons (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 Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: By Initial: O "Aboveground storage tank means a tank that has the capacity to store 55 gallons or more ol petroleum. "Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09119/08