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SAN JOAQUIN COUNTY ,,.JIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: 1 Page of �{"M�/ Facility Address: Ci Inspecfrion te: FA #: PR #: ProgramElement: 061,00 1 Jq 9 _3j 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) [ Containers (2821) #of Containers: J TA#:// 1 Product Type: Total Capacity: Z,� gallons (per tank or cumulative for containers by product type) Install Date: Vf�Tank (2820) ❑ Containers (2821) #of Containers:: T -A/#:: 2 Product Type:1 Total Capacity: �500 gallons (per tank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 3 Product Type: f/ /,// / /C ov 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 Product Type: kl o lnY C� / Total Capacity: � (l � gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: O gallons Total Capacity for Site: 1;1 jL' gallons Comments: EHD Inspe or: Reviewed Date: I , / Entered Date: r By Initial: u�' 1 6 I l•ll By Initial: *Abovegrou d storage tank means -a tank that has the capacity to store 55 gallons or more of petroleum. **Contain -r means a storaqe device desiqned to be moved when full. EHD 28-01 REV 04/19/12 AST SURVEY FORM