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ftSAN 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 of Facility Addr ss: City: Inspe ion Date: FA#: PR#: Prog amTn7t: 5" o Y Q4fl5'3D23;)�? g 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. L!J Tank (2820) ❑ Containers (2821) #of Containers: T4#: 19,5 s 1 Product Type: �� / Total Capacity: r �o gallons (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: I ?&c3(o 2 Total Capacity: / b 6'v gallons Product Type: agaiJ (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: ,/o"-3 3 Product Type: Total Capacity: l�J gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) 218ontainers (2821) #of Containers: y TA#: S!8 LP 3 J� 4 Total Capacity: % gallons Product Type: /l7 p T� (per tank or cumulative for containers by product type) Install Date: ElTank (2820) 21 ontainers (2821) #of Containers: TA#: -6-/ 5 r Product Type: �f�� a` C/ Total Capacity: �J gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 2 gallons Total Capacity for Site: C gallons Comments: EHD Inspector: Reviewed Date: Entered Date: C • v By Initial: VA I b" I By Initial: C "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