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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 Na Page -/ - Of,L— Facility Address: C' y: Inspect* Date: K5 `70 ;,r- - ; j aT r'11�� ; D FA#: O 79' PR#: Program Element: Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum x1,320 gallons in tanks`and containers". Complete one box for each tank or each cumulative container product type. C3'Tank (2820) ❑ Containers (2821) #of Containers: TA#:_ 1 �D gallons Product Type: Total Capacity: / Q (per tank or cumulative for containers by product type) Install Date: I, - ank (2820) ❑ Containers (2821) #of Containers: TA#: S 2 Z) l 7 Product Type: Total Capacity: IP gallons (per tank or cumulative for containers by product type) Install Date: �� 5 El Tank (2820) #of Containers: TA#: � Containers (2821) T 3 Product Type: ��/�✓ D�Y �� Total Capacity: // gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) eContainers (2821) #of Containers: �_ TA#: 19D 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: -Z / S gallons Total Capacity for Site: 2-1 gallons Comments: EHD Inspector: ReviewedDate: Entered Date: * By Initial: AA 31- 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