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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: DL f -r -Page of _-L Facility Address: City: Inspecti n Dat �- /gid P z3�of /'r fl FA #: PR M Program Element: 3() 0 L Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum >_1,320 gallons in tanks` and containers". Complete one box for each tank or each cumulative container product type. Tank (2820) ElContainers (2821) #of Containers: TA#: 1 Product Type: s'p Total Capacity: r y: ') ( ,tom, gallons (per tank or cumulative for containers by product type) Install Date: #of Containers: TA(�#: 0,ti 1 gg to /Tank(2820) ❑ Containers (2821) 2 Product Type: Total Capacity: j C)r� ?)gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: (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 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: i r gallons Total Capacity for Site: f �' gallons Comments: EHD Inspector: Reviewed Date:Entered By Initial: '1 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