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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: v © 3 Page of Facility Address: City: Inspej�io Dat FA#: PR#: Program Element: 0300 a5 moa qA- �� V 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. Et"Tank (2820) ❑ Containers (2821) #of Containers: TA#: ©5c3Do2�� 1 Total Capacity: SO 0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: 42' I ank (2820) El Containers (2821) #of Containers: TA#: 3D 2 Product Type: Total Capacity: /,09pz) gallons (per tank or cumulative f r containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Total Capacity: Z2 0 gallons Product Type: (per tank or cumulative for containers by product type) Install Date: ank (2820) ❑ Containers (2821) #of Containers: TA#: Q t5 c 0.2, 4 Total Capacity:y C� gallons Product Type: �r5'S /� (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: gallons Comments: EHD Inspector: Reviewed Date: Entered Date: By Initial: �.(p 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