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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: , T 0 ft r 1v ' !: L- ! 14 A R � Page % of Facility Address: G City: _ ff3 Inspecti n Da � d r FA #: � � PR #©� � / � ' a L! Progragn Elemen . "'z o -3 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) ElContainers (2821) #of Containers: TA#:�/ 1 Total Capacity: G d gallons Product Type: e,9 (per tank or cumulative for containers by product type) Install Date: [Tank (2820) El Containers (2821) #of Containers: TA#: Q,6_1 / (o 2 Product Type: e Total Capacity: �v�d gallons l (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: IS 2 3 // Product Type: Total Capacity: 0-e) 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: r �j` �� gallons Comments: EHD Inspector: Reviewed Date: By Initial: 01 Entered Date: By Initial: l( D *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