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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 Nam Page of l S Facility Address- City: Inspec on at "//_W lid 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. O"fank (2820) ElContainers (2821) #of Containers: TA#: Total Capacity: OD gallons Product Type: 1� (per tank or cumulative for containers by product type) Install Date: L•1 Tank (2820) ❑ Containers (2821) #of Containers: TA#: 2 Product Type: Total Capacity: !' gallons yp (per tank or cumulative for containers by product type) Install Date: U Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3Product Total Capacity: S J� gallons Type: (per tank or cumulative for containers by product type) Install Date: Cl Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4�' all Product Type:�d Total Capacity: S d � gallons (per tank or cumulative for containers by product type) Install Date: P --tank (2820) ElContainers (2821) #of Containers: TA#: D 5 0 p o Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: % 3 S gallons Total Capacity for Site: / Z s �- gallons Comments: J rn Ivn.in,✓ '' © 1` ! v 6- r6' cl `- o S S 7110 EHD Inspectgr: Reviewed Date: By Initial: (�,(�.�� Entered Date: By Initial: "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