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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: Page __L_ of Facility Address: City: Ins pe tion Date: FA#: PR M Program Element: l6 -7 j2 zeq 9 �n 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/ #: 1 Product Type: Total Capacity: 0 0 0 gallons (per tank or cumulative for containers by product type) Install Date: "Tank (2820) El Containers (2821) #of Containers: TA#: 2 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: [Tank (2820) ❑ Containers (2821) #of Containers: TA/#: 3 �0�� Product Type: �C� C��t . Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) containers (2821) #of Containers: Z TA#: 4 Total Capacity: f / (� gallons Product Type: �/'�da C f D/� , G��'LGH✓t�� (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Id6ontainers (2821) #of Containers: 2 TA#: 5 Product Type: Total Capacity: )/ D gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: gallons Total Capacity for Site: gallons Comments: A VT 1 Ar EHD Inspector: Reviewed Date: Entered Date: By Initial: 2_3_ r By Initial: "Abovegr and orage tank means a tank that has capacity to store 55 gallons or more of petroleum. "'Containe ans a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08