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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 Namp 0 �.-� Page / of l Facility Address: City: Inspect' n Dat 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. VTank (2820) ❑ Containers (2821) #of Containers: TA#: &S)qq�� 1Product Type: Total Capacity: �c�p gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: P6-1 2Product Type: Total Capacity: �0 8 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) El Containers (2821) #of Containers: TA#: 3 Product Type: �i-;O r Total Capacity: J-r� gallons (per tank r cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 4Product Type: R Total Capacity: l,1`O gallons (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: gallonsl Total Capacity for Site: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: g.2 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