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SAN JOAQUIN COUNTY so ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 4. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: Page % 6, of Facility Address. f 1 n City: 1►.ttp & ; ?0&X/j17 "r � 4IHACN Inspecti n Date: � o ,7 FA #: PR #: Progr m Element: 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#: R I 1 Product Type: / -� Total Capacity: � 0 l.� C) gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: ,TA#: 2 Product Type: Total Capacity: gallons - (per tank or cumulative for containers by product type) Install Date: I ank (2820) ❑ Containers (2821) #of Containers: _ TA#- 3 Product Type: Total Capacity: gallons (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 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: go gallons Total Capacity for Site: '? � gallons v Comments: EHD Inspector: � eviewed Date: rByInitial: �,,l��i Entered Date: 02% By Initial:L2 *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